Neurological Rehabilitation Centre

Edgware Community Hospital

Burnt Oak Broadway

Edgware, Middlesex

HA8 0AD

Tel: 020 3758 2465

Fax: 020 3758 2464

REFERRAL FORM

The information requested is essential to help us to decide on the appropriateness of the Neurological Rehabilitation Centre (NRC) for your patient and how we will best meet their needs. Your assistance in completing the form is appreciated since incomplete forms will not be accepted and will result in delay.

Please tick the box to indicate the type of service you are seeking (please see information sheet on reverse for service definitions).

Inpatient Multidisciplinary Assessment and Rehabilitation admissions (average period of 6-8 weeks).

Inpatient Multidisciplinary Assessment and Condition Management Programme (average period of 6-8 weeks).

Community/Outpatient Assessment and Rehabilitation or Condition Management Programme (average 4-8 weeks)

Vocational Rehabilitation

Long Term Conditions Register review – 3, 6 or 12 months.

In addition to the information requested in this form we require detailed medical and therapy reports outlining the clinical status of the patient including their therapeutic goals and recent progress.

If you would like to discuss the appropriateness of a potential referral, or prioritisation criteria or potential timeframe for assessment please contact:

Neurosciences Clinical Lead for Rehabilitation

Tel: 020 7794 0500 Ext 22167

or

Community Neurological Conditions Management Team Lead

Tel: 020 7794 0500 Ext 22123

NRC administrator email:

(inpatient) (CNCMT/ Voc rehab)

Royal Free Neurological Rehabilitation Centre June 2016 tel 020 7794 0500 ext 22148 Fax 020 3758 2465

Further information for Referrers:

Services offered: / One
Inpatient MDT Assessment and Rehabilitation / Two
Inpatient MDT Assessment and
Condition management / Three:
Community Assessment and Rehabilitation or Condition Management / Four:
Vocational Rehabilitation / Five:
Long term conditions register
Patient profile / Patients with a neurological LTC, who require intense, focused intervention, to regain aspects of functional independence. Their needs exceed what can be met through community or outpatient services. / Patients with a neurological LTC who require specialist inpatient intervention to manage their condition and any secondary complications.
To prevent acute admissions or extended length of stay. / Patients with neurological LTC, who require intense, goal-focused intervention, to regain aspects of functional independence in their own home and community or to manage their condition and any secondary complications in the community or within their own home / Patients with a neurological conditions who require support to:
• maintain work roles
• return to work from a period of sick leave
• seek new work roles
• considering medical retirement / Patients with progressive neurological LTC, currently in the community who require a MDT review and recommendations for ongoing management or patients with a Long Term neurological condition who have clear clinical reasoning to support the need for a review by the community team.
Time Frame / Typically 6 to 8 weeks / 6 to 8 weeks / Typically 4-8 weeks / 2-12 sessions / At least 12 month reviews
Service Provided / Pre assessment
MDT input by specialist clinicians based on assessment findings.
Individual rehabilitation programme with long and short term goals.
Discharge planning including home assessment and transfer of care sessions. / Pre assessment.
Specialist MDT assessment and intervention including:
Postural, Pressure care and spasticity/Contracture management.
Discharge Planning
Including home assessment, equipment/support services recommendation, transfer of care sessions. / Assessment.
Uni or multi disciplinary input by specialist clinicians based on assessment findings.
Patients with neurological LTC, who require intense, goal-focused intervention, to regain aspects of functional independence in their own home and community or to manage their condition and any secondary complications in the community or within their own home. / Triage and signposting
Specialist assessments and recommendations in relation to work activities
• supporting decisions
• co-ordination of individual specialist rehabilitation programmes designed to educate, support and advise on employment issues
• support to access relevant vocational support resources
• work site visits, employers and work recommendation reports
• 6 month review / Provision of a named contact and planned review service. Completed by phone, uni or multi disciplinary outpatient clinic or home assessment Provide regular reviews (min 12 monthly) to provide ongoing support to patients with progressive conditions. This can be uni or MDT, community, outpatient or telephone clinics.. Include MS CNS clinics.
We are unable to accept individuals who: / Inpatient NRC Service
  • Require the services of a Regional Neuro-rehabilitation centre.
  • Require Stroke Rehabilitation (refer to FMH or local Stroke Service).
  • Require tracheostomy weaning, respiratory support or nasogastric feeding.
  • Have severe challenging behaviours or who are in a low arousal state.
  • Are treated under section of the Mental Healthcare Act.
  • Require Social Work assessment and intervention only.
Require Social respite or continuing care placement. / Community Neurological Conditions Management team (CNCMT)
  • Require Stroke Rehabilitation (refer to Barnet Intermediate Care Services ).
  • Have sudden onset neurological conditions without neurological investigation.
  • Clients with Parkinson’s disease who will be seen by the Edgware Hospital PD Clinic.
  • If the reason for referral is predominantly as a result of mental health diagnosis or learning disability.
  • Require advice only on care package provision (SW)
  • Require advice only on equipment provision referrals (SSOT).
Please note we do not have carers as part of our team –all care requirements need to be arranged via Social Services.
Referral process
Inpatient service / Referrals are discussed at a Tuesday afternoon referral meeting and we aim to assess the patient within 5 sdays of the referral.
Community Prioritisation: / Referrals to the Community Neurological Conditions Management Team (CNCMT) are screened daily and will be prioritised according local policy and to clinical need. The CNCMT consists of a Consultant Neurologist, MS Specialist nurse, OT, PT, SALT, neuropsychologist, dietician and rehabilitation assistants. Please note we do not have carers as part of our team –all care requirements need to be arranged via Social Services.

Royal Free Neurological Rehabilitation Centre June 2016 tel 020 7794 0500 ext 22148 Fax 020 3758 2465

Neurological Rehabilitation Centre

EdgwareCommunityHospital

Edgware HA8 0AD

Tel: 020 3758 2465

Fax: 020 3758 2464

Name and contact of Professionals and services involved:
Name / Telephone
Social Worker
OT
Physio
SALT
Dietician
Psychologist
District Nurse
Day Services
Mental Health Services
MS Therapy Centre

Other

CLINICAL INFORMATION

1.1Diagnosis (including date/onset of condition):

1.2 Medical History:

Medical Disorders: (please tick)Medical/Surgical Procedures:

 Diabetes  Gastrostomy tube

 Heart failure Nasogastric tube

 Hypertension Tracheostomy tube

 Epilepsy Ventricular shunt

 MRSA positive Urinary catheter

 HIV positiveSupapubic catheter

 Known hepatitis Other procedure (state)

 Other infectious or communicable disease

1.3 Previous functional Ability within the last year (Mobility, Transfers, Activities of Daily Living, Occupation):

1.5 Summary of Medical History:

1.4 Social Situation and Home Environment:

1.5 Summary of Current Impairments (Body Functions and Structure):

Physical (motor and sensory)
Sensory (vision, hearing, sensation, pain)
Bladder/Bowel/Sexual Functioning
Pressure Care (Waterlow)
Physiological Functions:
Cognition and Perception:
Psychosocial (Mood, Behaviour, interaction)
Sleep, Energy and Fatigue
Communication
Swallowing
Nutrition / Nutritional Screening Tool completed (e.g. ‘MUST’)? Yes  No 
Nutritional Screening Tool risk category: Low  Medium  High 
Height: Weight: BMI:
Unintentional weight loss in the last 3 to 6 months? Yes  No 
Under hospital or community dietitian? Yes  No 

1.6 Current Functional Status:

Mobility (indoor/outdoor/stairs/
bed mobility):
Functional Transfers:
Personal ADL (wash, dress, toileting, feeding)
Specialist Seating needs: / Yes/ No
Wheelchair Type:
Seating Tolerance:
Splints/Casts: / Yes/No
Regime:
Carer/ Childcare commitments
Vocational situation
Community participation

1.7 Reason for Referral; include therapy goals, estimated length of stay/ intervention, anticipated

discharge destination:

1.8 Patient and family expectations of referral:

Royal Free Neurological Rehabilitation Centre June 2016 tel 020 7794 0500 ext 22148 Fax 020 3758 2465