<p>Transition Care Program Referral Form </p><p>Bed Based Community Based</p><p>Reason/s for referral: ______</p><p>TCP goals: ______</p><p>Patient/family goals/expectations: ______</p><p>Section 1: Referral Source/ Information:</p><p>Internal Referral External Referral – Health Network: Referral Date:</p><p>Referrer: Contact details: </p><p>Referral Reason: </p><p>Patient Location/ Ward Ph: Treating Team/Reg Pager: </p><p>Admission Date: </p><p>ACAS Approval: Yes No </p><p>Approved For: Permanent Care Respite Care- High/Low Flexible Care Home Care Package Level:</p><p>Delegation Date: / / ACCR Lapsing date: </p><p>Discharge Destination (If Known):</p><p>Section 2A: Client Details: Marital Status: Country of Birth: </p><p>Language/s spoken: Interpreter needed/ not needed (please Circle)</p><p>Pension No: Pension Type: </p><p>Medicare No: Medicare Expiry: </p><p>DVA No: DVA Card Colour: Gold White Blue Orange</p><p>GP Name: GP Contact Details:</p><p>Section 2B NOK/ VCAT/ EPOA Details:</p><p>NOK (1): Mr/Mrs/Ms/Miss Relation to Client: </p><p>NOK Address: </p><p>NOK Ph: (Home) (Work) (mobile) </p><p>NOK (2): Mr/Mrs/Ms/Miss Relation to Client:</p><p>NOK Address: </p><p>NOK Ph: (Home) (Work) (mobile) </p><p>VCAT/ EPOA</p><p>VCAT Application Submitted: Yes No Application for Guardianship/ Administration/Both</p><p>Applicant Details Name: Address: Ph:</p><p>Date Submitted: Hearing Date (If Known):</p><p>EPOA/ Administrator: Yes No Name: Ph: </p><p>Medical EPOA: Yes No Name: Ph:</p><p>Guardian: Yes No Name: Ph:</p><p>Advanced Care Plan Yes No Details: </p><p>Section 3: Medical Information:</p><p>History of Presentation:</p><p>Past Medical History:</p><p>Ongoing Active Medical/Surgical Issues: Follow up plans/ Appointments:</p><p>Care requirements: Bariatric equipment required: ______</p><p>______</p><p>NWB UL: Duration of NWB :______Ortho review date:______</p><p>NWB LL: Duration of NWB :______Ortho review date:______</p><p>VRE+ / MRSA: Location of infection: ______</p><p>Contact Precautions/ Details: ______</p><p>Wounds: Location of wound:______</p><p>Dressing Regime/ Frequency:______</p><p>Other (Please specify below)</p><p>Section 4: Social, Functional and Cognitive Information:</p><p>Current Psychosocial Situation:</p><p>Lives alone Lives with Spouse/ Family/ Others:</p><p>Accommodation Type: House Unit/ Flat Facility: Other: </p><p>Accommodation Owner: Client owned Family owned Private Rental Other: </p><p>Main Social Supports:</p><p>HACC Services/ Frequency:</p><p>Home Care Package: Yes No Package Details (level and services): </p><p>Case Manager: Yes No Details: </p><p>Financial Issues: Yes No Details: </p><p>Legal Issues: Yes No Details:</p><p>Pre-morbid Current Ongoing Goals Mobility</p><p>(eg: ambulation including distance/gait aid, transfers, falls history, endurance)</p><p>Occupational Performance</p><p>(eg: Personal care, toileting, domestic and community occupations)</p><p>Cognition:</p><p>(eg: cognitive impairment/ delirium/ dementia diagnosis, MMSE/ RUDAS Score)</p><p>Communication</p><p>(eg NESB, need for interpreter non-verbal, expressive/receptive deficits)</p><p>Nutrition/Swallowing</p><p>(eg Diet, swallowing issues)</p><p>Section 5: Barriers to discharge</p><p>Please comment on any known or potential barriers to discharge including home mods, VCAT proceedings, family conflict etc</p><p>______</p><p>______</p><p>______</p><p> Please attach any further reports that may assist with the Transition Care Program referral process or discharge plan; ie: Social work and/or Allied Health VCAT reports, VCAT Medical reports, Neuropsychological reports etc.</p><p> If you are referring from within the networks of Western Health, Melbourne Health or Northern Health - email all referrals to: WHS - Transition Care Referrals </p><p> If you are referring from outside of these three networks, the email address for Western Health Referrals is: [email protected] </p>
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