ICANHO

The Suffolk Brain Injury Rehabilitation Centre

GUIDELINES FOR REFERRAL

Please complete all sections of the referral form to avoid any delay while information is sought. We would be grateful for as much medical and social information as possible, including any discharge summary, if available.[1]

Icanho provides a comprehensive community rehabilitation service for people
aged 18 or over with acquired brain injury including traumatic brain injury, stroke and haemorrhage.

The service offers specialist comprehensive inter-disciplinary assessment, identification of problems/goals and setting up of individually designed rehabilitation programmes.

The clinical team comprises of Neuro Specialist Occupational Therapists, Physiotherapists, Speech and Language Therapists, Social Worker, Neurologist, Neuropsychologists and Rehabilitation Assistants. The rehabilitation programmes may include day attendance at Icanho, work within individuals’ homes or in the local community, and will be regularly reviewed.

HOW TO REFER

Telephone enquiries are welcome but all referrals should be made in writing. All Referral Forms should be sent to:

Post: Rehabilitation Team Co-ordinator, Icanho, Chilton Way, Stowmarket, Suffolk IP14 1SZ

Fax:01449 776100(secure fax)

Email: (Please encrypt Referral Form with a password before sending. Please send password in a separate email.)

For any other enquiries, please telephone (01449) 774161

ICANHO – REFERRAL CRITERIA

Individuals referred to Icanho should meet the following criteria:-

  • Be medically stable and well enough to be able to benefit from community rehabilitation.
  • Be aged 18 or over.
  • Have a Suffolk Primary Care Trust GP.
  • Have an acquired non-progressive brain injury, including trauma, stroke, haemorrhage, infection or tumour. If individuals have multi-pathology, the brain injury should be their primary diagnosis. Any secondary problems should not be so significant that they exclude them from benefiting from brain injury rehabilitation.
  • For Stroke:- To be accepted following the acute episode when discharged from hospital to home or a place of residence in the community. Time frame for acceptance of referral is up to6 months from the point of discharge.

For other Acquired Brain Injury including Sub-Arachnoid Haemorrhage:- To be accepted following the acute episode when discharged to home or a place of residence in the community. Time frame for acceptance of referral is up to 1 year from the point of discharge.

In exceptional cases referrals may be considered for Icanho rehabilitation beyond these time frames with PCT approval, for example late detection of difficulties/disabilities.

  • Require an interdisciplinary approach with some or all of the different professional groups working towards common goals, including Clinical Neuropsychology, Occupational Therapy, Physiotherapy, Social Work/family support, Speech and Language Therapy and medical input from a Neurologist.
  • Require a highly specialist brain injury rehabilitation service that explores all areas of difficulty including social, family, emotional, adjustment to disability, vocational, physical, functional, communication, cognition and behaviour.
  • Have complex difficulties resulting from their brain injury, either with multiple problems or a single problem of great complexity. For example, this would include those people with complex physical needs or those with subtle cognitive and emotional changes.
  • Have the potential to benefit from, and the willingness to participate in, the rehabilitation process.

Those clients who have a primary mental health problem, or severe behavioural difficulties that cannot be managed in the community with specialist support, may not be accepted to this service. Every effort will be made to work in partnership with their families, or signpost to, the most appropriate services.

Those individuals with particular needs (for example with access, transport, continence, medication or meal-time needs) should be discussed with the Rehabilitation Team Coordinators at the time of the referral.

02/11/2018

ICANHO
REFERRAL FORM

PERSONAL DETAILS

Name / «Title»«Forename»«Surname»
Address
(including
Post Code) / «Patient_address_house»«Patient_address_road»
«Patient_address_post_town», «Patient_address_county»
«Patient_post_code»
Tel No / «Patient_preferred_telephone»
Date of Birth / «Date_of_birth» / «Gender»
Ethnic Group / «Ethnicity»
Religion/faith
Language(s) / 1st:«Main_spoken_language» / 2nd:

If not at above address, please give current location:

Address
(including
Post Code)
Tel No.

NEXT OF KIN DETAILS

Name / «Next_of_kin»
Address
(including
Post Code) / «Next_of_kins_address»
Tel No. / «Next_of_kins_telephone»
Relationship

CARER DETAILS (if different to Next of Kin)

Name
Address
(including
Post Code)
Tel No.

GP DETAILS

Name / «Usual_doctor»
Address
(including
Post Code) / «Sender_address_building»«Sender_address_road»
«Sender_address_post_town»
«Sender_address_county»
«Sender_post_code»
Tel No.

02/11/20181 of 4Education\Admin forms\Client

MEDICAL DETAILS

Principal diagnosis & site of damage
(if known)
Icanho classification (leave blank)
Date of onset
Scan results / MRI
CT
Other
Glasgow Coma Score
(GCS) / At incident / On admission to A&E
Post-traumatic Amnesia
Consultant(s) involved
Neurosurgery (details & date
if applicable)
Ongoing medical issues
Past medical history
Current medication (name drugs & dosage)

REASON FOR REFERRAL


*Please continue on a separate sheet if necessary and attach any relevant scans, test results and reports as necessary.

DOES THE PERSON REFERRED EXPERIENCE PROBLEMS IN ANY OF THE FOLLOWING AREAS?

 /

Please give details

Physical/mobility
Functional
Communication
Cognitive
Behavioural/Emotional
Social Interaction

SOCIAL AND WORK SITUATION (e.g. type of property, lives alone, family circumstances, work situation)

TRANSPORT NEEDS(if any)

OTHER AGENCIES INVOLVED OR REFERRED TO AT DISCHARGE (include contact name and telephone no.)

IS THE INDIVIDUAL AWARE OF THE REFERRAL?

YESNO

REFERRER INFORMATION

Name: / «Sender_title_and_surname»
Discipline/relationship:
Address:
(including
Post Code) / «Sender_organisation_name»
«Sender_address_building»«Sender_address_road»
«Sender_address_post_town»
«Sender_post_code»
Tel No:
Signed:
Date: / «Date_of_referral»

Please send completed form to:

Post: Rehabilitation Team Co-ordinator, Icanho, Chilton Way,
Stowmarket, Suffolk IP14 1SZ

Fax:01449 776100 (secure fax)

Email:(please encrypt Referral Form with a password before sending. Please send password in a separate email)

For any other enquiries, please telephone (01449) 774161

02/11/20181 of 4Education\Admin forms\Client

[1] Icanho reserves the right to withhold/refuse treatment if essential elements of referral information are not provided.