PATIENT NAME: DOB:

NCL D2A Pathway 1
Referral form
Before referral, please confirm D2A pathway criteria are met - if they are not met this discharge pathway is not currently appropriate for this patient; in which case, phone and discuss alternatives with SPA. Criteria:
  • Patient is medically optimised and safe to be left between care calls (including being able to toilet safely)
  • Patient and / or family have agreed to assessment at home
  • Patient does not have an uncontrolled mental health condition or severe cognitive impairment which would put themselves or others at risk on discharge
  • Patient is not homeless (hostel residents can be referred)
All information in sections 1 – 3 and 7 must be provided. For sections 4-6 and 8 any information known is helpful.
Preferred referral route is by phone to SPA when form will be completed by SPA from your information and a copy e-mailed back; completed form can be made by e-mail but please be available for a call back. See also helpful questions at end of form to consider before making the referral
SECTION 1 REFERRER DETAILS
Date of referral: / Date of admission:
Date of discharge: / Planned time of d/c if known:
Referring hospital: / Ward:
Ward phone number:
Referrer: / Contact number/Bleep/Pager for call back:
SECTION 2 SERVICE USER PERSONAL INFORMATION
Name:
Telephone number (at home): / NHS Number:
Date of birth:
(Not for pts < 18yrs) / Gender:
Address: Postcode: Borough:
GP name: / NOK name:
GP Address: / Relationship:
GP Contact number: / NOK telephone number:
Reason for referral:
Anticipated reablement or Long-term support
Anticipated areas of improvement:
SECTION 3 REASON FOR ADMISSION AND ONGOING MEDICAL NEEDS
Reason for admission:
Current active health concerns:
Actions for GP:
Out-patient follow up, appointments details if known:
Discharge letter must also go with patient when discharged:
SECTION 4 CURRENT FUNCTION
Patient is consistently able to transfer and mobilise as needed to be safe between calls Yes
List any mobility issues (aids, supervised/unsupervised):
List any transfers required (aids, supervised/unsupervised):
List any equipment the patient is to be discharged with:
List post-op precautions/weight bearing status (if applicable):
Assistance described should be “non-therapeutic” handling – family/carer level
SECTION 5. HEALTH – ANY ISSUES IDENTIFIED AND / OR MEASURES TO ADDRESS IN PLACE
Medication (blister/single pack, prompt/self-administer):
Toileting (how will toileting be managed between care calls and at night):
Skin integrity (pressure area concerns, continence, wounds):
Nutrition (swallow concerns, modified diet):
Has a district nurse referral been made?
No Yes If yes, please specify reason:
SECTION 6ANTICIPATED SUPPORT NEEDS / CARE
Is there an existing care package? Yes No Don’t Know
Package of care anticipated Yes No Don’t Know
(based on current needs in hospital – POC will be finalised at home assessment)
MorningLunchTea time Evening
Anticipated care needs:
SECTION 7 ACCESS ARRANGEMENTS (IN ORDER FOR ASSESSOR TO GAIN ACCESS FOR ASSESSMENT
Client can answer the door / Intercom / Keysafe (please provide details below) / Family member to open
Further detail on access:
Any known concerns regarding home environment to be addressed by community staff:
SECTION 8ANY OTHER INFORMATION COMMUNITY STAFF SHOULD KNOW PRIOR TO FIRST VISIT
(e.g. Any cognitive impairment identified, resolving delirium, behavioural concerns, risks to lone workers, service user preferences)

Speak to or send completed form to either:

  • / 0845 389 0940 [Barnet residents]
  • / 07714 597309[Camden residents]
  • 020 8379 3449 [Enfield residents] telephone number only
  • / 020 8489 1616[Haringey residents]
  • / 020 7527 8087[Islington residents]

Copy completed form to:

  • (Barnet Hospital – All patients)
  • (Royal Free Hospital – All patients)
  • (UCLH - All patients)
  • (Whittington hospital – All patients)
  • (North Middlesex hospital – All patients)

Office Use
Recommended professional for first visit:
Requires double up at first visit:
Time and date of first visit:

Questions to consider before making the referral

This is not part of the referral form but if you are unfamiliar with making a pathway 1 referral these questions will help you gather the appropriate information before you make the call.

The person making the referral will be expected to be able to describe how the person is managing on the ward in order to determine that they are safe to be left between care calls and how much initial help they will need.

Likely questions – on the ward:

  • Is the patient able to move themselves in bed?
  • How many people are required to help the patient out of bed?
  • Are they able to walk to the toilet themselves, if not how many people are needed to assist?
  • Are they able to toilet themselves or do they require assistance?
  • Do they need help having a wash or dressing themselves?
  • Does the client use a walking aid on the ward to transfer or mobilise and do they need supervision or assistance?
  • Are they trying to get out of bed or chair on their own?
  • Are they likely to fall if trying to get up unaided?
  • Are they wandering or trying to leave the ward?

If not safe to be left between calls, please consider an alternative discharge plan/pathway; this can be discussed with SPA who may be able to advise.

Does a CHC checklist needs completing? If so please attach to this referral

North London PARTNERS in health and care

Pathway 1 referral form – without an SPA

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