WILLEN HOSPICE

Referral & Admission

Policy & Procedure (CL025)

Approved By Senior Management Team Date of Revision January 2104 Amended By F Wordley Revision Number 4 Revision Due By January 2017

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Contents Section number & title: Page 1. Policy Statement/Introduction 3 2. Responsibility/Accountability 3-4 3. The aim 4-5 4. Hospice Services 5-6 5. Eligibility Criteria 6 6. Geographical boundaries 6 7. Who can refer 6-7 8. Referral criteria 7 9. Referral Process 7-8 10. Dissemination of referral criteria information 8 11. Lymphoedema service referral 8-9

12. Daily Multi-Disciplinary Team (MDT) Meeting 9

13. Daily MDT Meeting Format 9

14. Actions following daily MDT meeting 9-10

15. Complex Admissions 10

16. Internal Hospice Department Referrals 10

17. Discharge of Patients from Willen Hospice Services 10-11

18. Audit 11

Appendix 1: GP practices & CNS cover 12-19

Appendix 2: Willen Hospice Referral Form 20-21 Appendix 3: Admissions requested after the Daily MDT

Meeting Flow Chart 22 Appendix 4: Referral Criteria & Pathway Flow Chart 23 Appendix 5: Willen Hospice at Home Service Patient

Assessment Form 24-25 Appendix 6: Willen hospice Internal Department Referral

Form 26 Appendix 7: Lymphoedema referral Form 27-28

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WILLEN HOSPICE

Referral & Admission Policy & Procedure (CL025)

For the purposes of this document the term ‘the Hospice’ relates to Willen Hospice and Willen Hospice Ventures and the term ‘staff’ relates to employees, bank & agency staff and volunteers.

1. Policy Statement/Introduction

This policy is designed to: Provide guidance on accessing all the services provided by

Willen Hospice. Identify the eligibility criteria for access to services Identify any barriers to accessing services Identify those referring bodies to whom the information will be

disseminated Identifying the clinical staff responsible for following the

admission process and undertaking review of access arrangements and response times

Define the documentation requirements Identify the time parameters for access to services and response

times

2. Responsibility/Accountability Ultimate Responsibility Registered Manager*

To ensure that the policy and procedure regarding

treatment and care and access to services are adhered to; and that services are provided which are non-discriminatory, appropriate and timely. To receive regular reports on access arrangements and response times.

First Line Responsibility All Clinical Heads of Department

To establish eligibility criteria for access to services. To ensure that access to the services provided by the organisation is non-discriminatory, appropriate and timely. To ensure that clinical staff are appropriately skilled in all aspects of assessment across all domains, and skilled in determining when to refer the patient/carer to another external health and/or social

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care agency. To provide reports on access arrangements and response times.

Additional Responsibility All Clinical staff To follow all internal procedures regarding access to

services ensuring that access is non-discriminatory, appropriate and timely. To be able to assess the needs of patients and carers across all domains prior to access to services using reported information, ensuring that referral to alternative health and/or social care agencies are made if admission/acceptance to the Specialist palliative care provider is deemed inappropriate. To work within the limits of own clinical competence and seek advice where appropriate.

3. The aim

The aim of the Hospice is to offer patients aged 18 years and over with advanced life limiting illness, care which addresses their physical, social, emotional, spiritual and psychological needs, improving their quality of life and enabling them to live as full a life as possible in their remaining life span.

This will involve assessing their needs following referral and during the care to try and ensure these are met.

This may involve symptom control with medication and/or referral to related support teams including Clinical Nurse Specialists (CNS), Hospice at Home Team (H@H), Hospice Chaplain, Patient & Family Services Team, Occupational Therapy, Physiotherapy or Speech & Language Therapy.

To achieve this aim, the following are essential:

Formal referral guidance and processes for the service that are understood and agreed by key stakeholders

Collaborative working with key stakeholders in local services and those making referrals: General Practitioners (GPs) Community nursing teams (CHCS)and allied health

professionals (AHPS) and their managers Community Health Service Managers e.g. Continuing Health

Care (CHC) funding team Hospital based consultants, nurse specialists, at local

hospitals, cancer centres and other places involved in the care of a client

Collaborative working with local Cancer treatment centres, Cancer Network contacts and other specialist services

Open access to assessment and consideration of peoples’ needs by the Clinical Nurse Specialist (CNS)or In Patient Unit (IPU) Teams

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Provision of opportunities for education, mentorship and support for local community service colleagues through care of clients and other routes

Evaluation of service outcome Hospice services as outlined below

4. Hospice Services The Hospice offers the following support and expertise:

Community Services Clinical Nurse Specialists Specialist advice and support to patients and other health

care professionals Symptom management in liaison with the Primary Health

Care Team (PHCT) Emotional Support

Hospice at Home Service

Accessed via the CNS service, or by direct referral, this team offers symptom control and end of life care to patients in their own home in collaboration with the MKCHS.

Complementary Therapies

Day Hospice Specialist service open 3 days per week. Symptom management/advice Support through palliative care treatments Psychological, emotional and spiritual support Care planning Diversional therapy Complementary Therapies

In Patient Services

Symptom control Emotional, Psychological and Spiritual Care Supportive care End of life care Average length of stay is 8 to 10 days

Lymphoedema

Specialist massage and bandaging Medical concept taping Manual lymphatic drainage (MLD) Teach simple lymphatic drainage (SLD) Complete Decongestive Therapy Compression bandaging & compression garments Skin care advice All treatments are individually assessed as appropriate

Medical Support Within the In Patient Unit

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Out-patient clinics Domiciliary Visits

Patient & Family Service

Patient & Carers Support Services Young People’s Support Service(young people up to the

age of 18) Pre & Post Bereavement support

There is also access to the following services once patients are

registered with the Hospice: Chaplaincy Hospice at Home Befriending Service

Where necessary the Hospice will work with other external Health and Social Care Services to enable the continued provision of Specialist Palliative Care

5. Eligibility Criteria

The Hospice offers specialist palliative care services to patients aged 18 years and over with a diagnosis of cancer and other life limiting illness.

Other diagnoses are assessed for suitability and accepted if the problem is deemed to be within the specialist palliative care expertise of Willen Hospice.

The Hospice team will carefully assess patients who are referred for Specialist Palliative Care and who have an underlying diagnosis of senile dementia e.g. Alzheimer’s disease, learning disability or profound psychiatric illnesses, as maintaining patient safety is paramount. However, support and advice may be provided within the patients’ own environment on request.

Due to demand for services particularly in the Inpatient Unit the Hospice cannot accept requests for planned respite admissions nor can the Hospice offer long term inpatient care.

6. Geographical boundaries

Referrals are accepted for patients registered with GPs in the following Primary Care Trusts: Milton Keynes Northamptonshire (Hanslope Practice only) Bedfordshire (parts only) Aylesbury Vale (parts only) Leighton Buzzard (parts only)

GP practice list and CNS attached (Appendix 1)

7. Who can refer Referrals can be made by any professional involved in the

patient’s care, and from patients and carers themselves. In cases of self-referral, or a non-professional referral, the

CNS/IPU/Day Hospice team will have to discuss this with the

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patient’s GP, and be in receipt of a referral form completed by a clinical professional who has knowledge of the patient.

It is essential that any referral is discussed with the patient before being made as consent to referral enables the CNS/IPU/Day Hospice teams to work in an open manner with the patient.

8. Referral criteria

Referrals can be made for any patient with cancer or other life shortening illness requiring – Complex symptom control Specialist information needs Psychological/emotional support End of Life Care i.e. the last few weeks of life

9. Referral process

Referrals can be made using the completed Referral form submitted by post or fax to the Hospice Clinical Administration Office on 01908 306993. These must be completed fully.

Copies of Referral forms are available from the above office telephone: 01908 663636. (Appendix 2)

Any incomplete referral forms sent in will be returned for further information and no action will be taken by the Hospice until it is returned satisfactorily completed.

All referrals are recorded by the Medical Secretary and taken to the following day’s morning Multi-Disciplinary Team (MDT) meeting for review and decision on acceptance.

Urgent referrals received will be reviewed by the Senior Nurse Manager and/or Hospice Doctor prior to the morning MDT meeting if required. (Appendix 3)

If the referral is not felt to be appropriate by the MDT, the Medical Secretary will write to the referrer to inform them of this decision explaining the reasons for the decision.

Once accepted, the patient details will be placed on ICARE – patient electronic records information system - and a unique ID number given. A set of patient records will be prepared.

The response time from the date of receipt of the referral will normally be within two working days. This response can either be telephone contact to arrange an appointment or a visit to the patient if appropriate. Where appropriate the response of the Hospice may be an outpatient appointment or domiciliary visit to ensure patient’s clinical needs are met.

If the referral is for Day Hospice/ Clinical Nurse Specialist/Hospice at Home community support – notes will then be passed to the Day Hospice/CNS/Hospice at Home team to make contact.

The Hospice at Home Team will complete their own assessment

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form upon contact with the patient (Appendix 5) If the referral is for In Patient Unit Admission – notes will be

passed to the Ward Clerk/Nurse in Charge and contact will be made to arrange admission.

Links will be made to other Hospice services as agreed in co-operation with the patient and carers i.e. Family Support Worker, Bereavement service, Carers drop in.

NB: Out of hours referrals to the Hospice at Home Team may be made after the 9am multidisciplinary meeting on Friday but will be accepted at the discretion of the on-call Hospice manager. A referral form will need to be submitted to the Hospice as soon as possible. Once received the Hospice at Home team will be able to introduce the service and arrange a visit to the patient. The referral will be presented at the 9am multidisciplinary meeting the following Monday.

10. Dissemination of referral criteria information General Practitioners in identified PCTs Social Services Milton Keynes NHS Foundation Trust

Clinical Nurse Specialists Hospital Consultants Wards

District Nurses Community Advanced Nurse Practitioners Motor Neurone Disease Association Clinical Commissioning Group Northampton General Hospital –

Talbot Butler Ward Clinical Nurse Specialists Oncologists

Other Hospitals - on request

11. Lymphoedema service referral Referrals made on Lymphoedema referral form (Appendix 7) and

available from the Lymphoedema service on 01908 663636. Geographical boundaries are as the Hospice information above. Service available to patients who have developed lymphoedema

secondary to cancer treatments or cancer itself. Patients with primary lymphoedema, where they were born with

the condition due to underdeveloped lymphatics, can also be referred.

Referrals can be made by health care professionals involved in the patients’ care.

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Once the referral has been reviewed by the Lymphoedema team, it is taken to the daily MDT meeting and a decision is made re the appropriateness of the referral.

Once accepted, an appointment is made for the patient for an assessment by a lymphoedema specialist nurse.

Services available are detailed in Section 4 – Hospice Services

12. Daily Multi-Disciplinary Team (MDT) Meeting The admissions (excluding emergency admissions) will be

prioritised and agreed at the daily meeting of key members of the clinical team. These are:

Senior Nurse Manager Senior Sister Member of the In Patient Unit Nursing Team Member of the Medical Team Member of Patient & Family Services Team Member of the Clinical Nurse Specialist Team

Member of the Hospice at Home Team Member of the Day Hospice Team Member of the Lymphoedema Team Hospice Chaplain Medical secretary

Other Hospice service team members may attend as

appropriate and visiting healthcare students and professionals are welcome to observe the workings of the meeting

This meeting will take place at 9am Monday to Friday. At weekends each potential admission will be discussed between the Doctor on call and the CNS on call/Senior Nurse in IPU before agreement to admit the patient is made.

13. Daily MDT Meeting Format

IPU Nurse – gives handover on in-patients – with brief details: name, age, diagnosis and present condition.

Patients ‘Pending’ on the bed state list are then reviewed and discussed.

Patients ‘To be aware of’ on the bed state list are then reviewed and discussed.

‘Hospital patients’ on the bed state list are then reviewed and discussed.

Through MDT discussion – admissions are prioritised & agreed.

Referrals that have been received are then reviewed & accepted, if appropriate.

Decisions regarding referrals are documented by Medical

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Secretary/Ward Clerk in Referral Register.

14. Actions following daily MDT meeting IPU nurse informs the following of expected

admissions/discharges: Reception, Kitchen Ward Clerk, Hostess

Notes made up by Medical Secretary/Ward Clerk and passed to appropriate department.

Ward Clerk/CNS organise transport & Ward Clerk completes transfer check list if appropriate.

Room is prepared to welcome patient admission. When a patient is admitted, they will be seen and assessed by

a Doctor/Nurse within one hour of admission. 15. Complex Admissions

If the admission is identified as being complex or potentially difficult e.g. presenting with unusual or particularly complex/complicate symptoms or difficult family dynamics, a meeting should be arranged to discuss the issues normally prior to the admission being made to the unit in order to ensure an agreed plan of action.

This meeting will normally be held within 48 hours of the referral being received.

Those attending the meeting will normally be: Medical Director Director of Nursing and Patient Services Senior Nurse Manager Relevant others e.g. Hospice at Home, Patient & Family

Services Manager, members of the Primary Health Care Team etc.

All discussions and action plans will be documented in the patient nursing records.

16. Internal Hospice Department Referrals

Inter department referrals are made on the Willen Hospice ‘Internal Department Referral’ Form accessed via the intranet under ‘Forms – Clinical’ (Appendix 6)

These must be completed as fully as possible and passed to the department concerned.

17. Discharge of Patients from Willen Hospice Services

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Willen Hospice will provide appropriate specialist palliative care services to patients whilst they are required whether in their own home (agreed areas), the Hospice Inpatient unit or other environments.

The Hospice reserves the right to review the provision of its services and to plan appropriate care for each patient in the future to meet changing care needs.

18. Audit

Adherence to the stated procedure will be audited annually

through an audit trail of a random selection of referral and admission episodes over the course of the year to ensure adherence with the principles above.

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Appendix 1: GP practices & CNS cover WILLEN HOSPICE Primary Care Groups are shown by each practice AVPC = Aylesbury Vale Primary Care Group DSNP = Daventry & South Northants Primary Care Alliance LBPC = Leighton Buzzard, Dunstable & Houghton Regis Primary Care Group MKPC = Milton Keynes Primary Care Group Practices covered by Clinical Nurse Specialists – MARCH 2012: SUE BOWER AVPC Norden House Surgery, Avenue Road, Winslow, Bucks, MK18 3DW Telephone 01296 713434 Fax 01296 715439 Dr Dickson Dr Fairfield Dr Straker Dr Mason Dr Ramasamy North End Surgery, High Street, Buckingham, MK18 1NU Telephone 01280 818600 Fax 01280 818618 Dr Harrington Dr Simons Dr J Pryse Dr R Pryse Dr Solola Dr Rizvi Dr Matthews Masonic House Surgery, 26 High Street, Buckingham, Bucks, MK18 1NU Telephone 01280 816450 Fax 01280 823885 Dr Robb Dr Largent Dr Quinie Dr Tjoa Verney Close Family Practice, Verney Close, Buckingham, MK18 1JP Telephone 01280 822777 Fax 01280 823541 Dr Brain Dr Siddique Dr Banks Dr Matthews Dr Hens

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SUE BOWER MKPC Stantonbury Health Centre, Purbeck, Stantonbury, MK14 6BL Telephone 01908 318989 Fax 01908 319493 Dr Okuzu Dr Iyamabo Dr Dhedhi Stony Stratford Health Centre, Stony Stratford, MK11 1YA Telephone 01908 565555 Fax 01908 575815 Dr H Jenkins David Taylor 07967 632791 Dr R Collins Dr A Goyal Dr S Grinyer Dr A Hamid Dr P Regis Dr S Rocque Stonedean Practice, Stony Stratford Health Centre, Stony Stratford MK1 1YA Telephone 01908 261155 Fax 01908 265818 Dr N Douse Dr C Bedford (P/T) Dr A Osakuade Dr S Whiteman CORA GRANFIELD MKPC Ashfield Medical Centre, 1 Perrydown, Wastel, Beanhill MK6 4NH Telephone 01908 679111 Fax 01908 230601 Dr A Yaya Joanne Burgess 07799 898641 Dr M Roy Dr M Cassidy Dr A Suleman Dr A Waheed Dr H Hilmy Dr Haye Dr Sheikh The Grove Surgery, Netherfield, MK6 4NG Telephone 08444 772478 Fax: 01908 295701 Dr S Anaman Dr S Bharamgoudar Dr A Sharma

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Fishermead Medical Centre, Fishermead Boulevard, Fishermead MK6 2LR Telephone 01908 609240 Dr A Berger Dr M Kansagra Dr Kerawalla Red House Surgery, 241 Queensway, Bletchley MK2 2EH Telephone 01908 375111 Fax 01908 370977 Dr Staten Jan Curtis 07799 898642 Dr Fagan Dr Goodman Dr Bunting Dr Muhsin Dr Marchand Dr Williams Dr Abdalwhab Westfield Road Surgery, 11 Westfield Road, Bletchley, MK2 2DJ Telephone 01908 377103 Fax 01908 374427 Dr V Cantaboo Dr M Robinson Dr A Cantaboo Dr Richards LIZ CHRISTODOULOU/ JULIE HOPPS MKPC Wolverton Health Centre, Gloucester Road, Wolverton, MK12 5DF Telephone 01908 222954 Fax 01908 314717 Dr G Halder Dr S Mushtaq Dr P Sen Dr S Mushtaq Dr S Raju Dr S Shun Watling Vale Medical Centre, Shenley Church End, MK5 6EY Telephone 01908 501177 Fax 01908 504916 Dr M Wyke Vendrice Garvin 07799 898648 Dr E Webb Dr M Edwardson Dr S Corbishley Dr P Berkin Dr J Slippe-Quartey Hilltops Medical Centre, Kensington Drive, Great Holm, MK8 9HN Telephone 01908 568446 Fax 01908 265028 Dr O Awudu Sheila Moran 07799 898634 Dr A Watson Dr M Dewji

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Dr H Toomey Dr B Patel Dr S Chrysostom Dr M Field Dr M Khiani Walnut Tree Health Centre, Hindhead Knowl, Walnut Tree MK7 7NR Telephone 01908 691123 Fax 01908 691120 Dr A Howard Dr N Siddiqui Dr S Sharif Dr A Nicolaou Dr T Withanage GRAHAM LEWIS MKPC 4 Bedford Street, Bletchley, MK2 2TX Telephone 01908 658850 Fax 01908 645903 Dr S Stranks Dr M Muhderbashi Dr H Ullah Dr A Shivapaty Furzton Surgery, 67 Dulverton Drive, Furzton Telephone 01908 867064 Dr R H Patel Dr M Jahngir Dr T Durojaiye Dr A Shivapaty Water Eaton HC, Fern Grove, Lakes Estate, Bletchley, MK2 3HN Telephone 01908 371318 Fax 01908 643843 Dr Arvind Karia Rose Kwarteng 07799 898646 Dr M Singh Dr I Kanjee Dr Amit Karia 20 Drayton Road, Bletchley MK2 3EJ Telephone 01908 371481 Fax 378700 Dr P Kusre Dr V Manjure Whaddon House Surgery, 25 Witham Ct, Tweed Drive, Bletchley MK3 7QU Telephone 01908 373058 Fax 01908 630076 Dr Tamina Siddiqui Dr Philbin Dr Hilmy Dr Bradley Dr Clerkin Dr Malik Asim

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Dr N Alam Dr B Swarnalakshmi Dr Rana – GP Trainee Dr Robinson – GP Trainee Parkside Medical Centre, Whalley Drive, Bletchley, MK3 6EN Telephone 01908 375341 Fax 01908 374975 Dr M Cave Pam Sharmen-West 07775 795105 Dr N Smith Dr P Minney Dr M Munro Dr C Kenny Dr P Nguyen Dr S Ellis JOY BUTLER MKPC Medical Centre, Queens Avenue, Newport Pagnell MK16 8QT Telephone 01908 611767 Fax 01908 615099 Dr C Hickson Dr I Carter Dr A Chandola Dr K Holowka Dr L James Dr Kufeji Dr R Mithen Dr F Mohri Dr F Mohri Dr S Weatherhead Dr Rocque Dr Thorncroft The Kingfisher Surgery, Elthorne Way, Newport Pagnell MK16 0JR Telephone 01908 618265 Fax 01908 217804 Dr A C Paton Dr A O’Brien The Surgery, Cobbs Garden, West Street, Olney MK46 Telephone 01234 490377 Fax 01234 711883 Dr D Bartlett Heather Ward 07775 795071 Dr B Partridge Dr M Winter Dr J Adams Dr J Walter KATE KNIGHT MKPC

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VANESSA GRICE Sovereign Medical Centre, Sovereign Drive, Pennylands, MK15 8AJ Telephone 08444771791 Fax 01908 234894 Dr S Muthuveloe Celia Ellis 07799 898637 Dr A Nasiri

Broughton Gate Health Centre, Glynn Valley Place, Broughton MK10 7AZ Telephone 01908 874444 Dr Laughton

The Surgery, 1 Western Drive, Hanslope, MK19 7LA Telephone 01908 510230 Dr Barter 07654 642782 Dr L Moore Dr Wedgebrow Dr Bafir

Westcroft Health Centre, 1 Savill Lane, Westcroft MK4 4EN Telephone 01908 520545 Fax 01908 520975 Dr J Ahmed Dr J Malik Dr A Ali Dr H Alifoe Dr S Godagama Dr N Patel Dr Shakir Dr Weatherhead

Oakridge Park Medical Centre, 30 Texal Close, Milton Keynes MK14 6GL Telephone 01908 224892 Fax 01908 224880 Dr M Mahendran Dr M Ahad Dr D Madhotra Dr B Mathews Dr K S Rajarathna

CMK Medical Group, 68 Bradwell Common Boulevard, MK13 8RN Telephone 01908 605775 Fax 01908 295657 Dr Amin Helen Lyne 07799 898636 Dr Jolly Zachariah Dr Susan Weatherhead Dr E Huish Dr Norman Dr F Webster Dr Sivills Dr C Manna

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Dr G Williams Dr M Owolabi Dr C Dzawanda Neath Hill Health Centre, 1 Tower Crescent, Neath Hill MK14 6JY Telephone 08444 773011 Fax 01908 696096 Dr M Prasad Dr V Rao Milton Keynes Village Practice, Griffiths Gate, Middleton MK10 9BQ Telephone 01908 393979 Fax 01908 393774 Dr D Moore Dr S Whyte Dr R Babatunde Dr M Sekharan Dr Khan Dr Garshom NB Surgeries in Woburn Sands have access to Willen Hospice inpatient unit beds. However, the community team do not visit patients in their own homes in these areas. The CNS in their respective areas can be contacted. The Surgery, 1 Leighton Road, Leighton Buzzard, Beds, LU7 7LB Telephone 01525 372571 Dr Hafez Dr Paruk ) Community input not from Willen Dr Patel ) Dr Gohar ) Dr Ansah ) Dr Scott ) Dr Turner ) 29 Bassett Road, Leighton Buzzard, LU7 7AR Telephone 01525 378387 Fax 01525 853767 Dr Chapman Dr Henderson Dr Horkan Dr Lucy Dr Jamal Dr Stewart Dr Knight AVPC Ashcroft Surgery, Stewley Road, Wing, Leighton Buzzard, LU7 0NE Telephone 01296 688201 Dr Dunford The Surgery, 46 Stewley Road, Wing, Leighton Buzzard, LU7 0NE Telephone 01296 688575

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Dr Lilley Dr Jones CVPC Salisbury House, Lake Street, Leighton Buzzard, LU7 8RS Telephone 01525 243890 Dr Marshall Dr Dry Dr Hoque Dr Josephidou Dr Wadud Dr Reeve 20-22 Lake Street, Leighton Buzzard, LU7 8RT Telephone 01525 851995 Dr Shafti

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Appendix 2: Willen Hospice Referral Form Medical Administrator – 01908 306985 Fax Number – 01908 306993

REFERRAL FOR (tick box) Received by – Sign and Date

Please Note: Referral for a Domiciliary Visit must be from a Doctor

1. Clinical Nurse Specialist …………………………………… 2. Hospice at Home

………………………………………..

3. Inpatient Care ………………………………… .. 4. Day Hospice

………………………………………..

5. Domiciliary Visit ………………………………….. 6. Lymphoedema Clinic

……………………………………

PATIENT DETAILS Surname First Names

D.O.B Age M F

Address

Post Code Tel No Marital Status

Current Location of Patient Hosp No

G.P Tel No

NHS No PCT

Ethnic Origin Religious Beliefs

Patients First Choice of Spoken Language

FIRST POINT OF CONTACT DETAILS REFERER DETAILS

Name Name

Address Address

Post Code Tel No Post Code Tel No

Relationship Relationship

DISEASE STATUS Diagnosis

Date of Diagnosis

Is patient aware of referral? Yes No if no, the Hospice is unable to accept referral Is GP aware of referral? Yes No if no, the Hospice is unable to accept referral

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Metastases/Complications

Disease Management: Active / Palliative

PATIENT NAME ……………………………………………… ICARE……………………………………… Patient’s Understanding of Diagnosis

Carers Understanding of Diagnosis

PLEASE ENCLOSE RELEVANT CORRESPONDANCE AND RESULTS

TREATMENT, PAST & CURRENT Surgery: Date: Surgeon:

Radiotherapy: Date: Oncologist:

Chemotherapy: Date: Oncologist:

Hormonal Treatment: Date started:

OTHER MEDICAL CONDITIONS:

CURRENT MEDICATIONS:

ALLERGIES: SPECIALIST PALLIATIVE NEEDS RECENT INTERVENTION RECEIVED BY MEDICAL ADMINISTRATOR ……………………………………………..(Date)

……………………………………………..(Sign)

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Appendix 3: Admissions requested after the Daily MDT Meeting Flow Chart

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Appendix 4: Referral Criteria & Pathway Flow Chart

To be referred to Senior Nurse Manager/Senior Sister for discussion with person making call

Senior Nurse Manager/Senior Sister to discuss with Doctor as available

Decision regarding admission to be fed back to person making the request

Admission Inform the IPU Nursing team Obtain Clinical Records Document reasons for admission

Declined admission Inform CNS team request was made Document in patient record reasons for decision

Requests for Admission after the daily clinical meeting

Is patient known to Hospice services? If ‘Yes’ proceed below

If patient unknown to Hospice service they should be referred back to the appropriate service for immediate

care by the person making the call e.g. hospital; emergency nursing home place

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The aim is to: Provide equitable access to Hospice services following a clear referral process

App 5: Willen Hospice at Home Service Patient Referral Form

WILLEN HOSPICE AT HOME SERVICE

Referrals – are accepted from all Health Care Professionals using the fully completed Hospice Referral Form; additional information e.g.

clinical results and letters are welcome. If a referral form is needed, contact the Hospice for a copy.

Any incomplete referral forms will be returned for full completion and no action will be taken until the completed form id returned to the

Hospice

Referral can be made directly to the following services

Patient & Family Services Patient & Carers Support Young Peoples Support Pre/Post Bereavement Support

Medical Services Out Patient Clinic Domiciliary visits

Lymphoedema In Patient Services Community

Services Clinical Nurse Specialists Hospice at Home Day Hospice

Appropriate Department responds

Icare entry created and Clinical Record prepared

Medical Secretary

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CONFIDENTIAL

PATIENT ASSESSMENT FORM Patient’s Name

Date of Birth:

Patient’s Address

Telephone Number: Access: Key Safe:

Name of referring District Nurse:

Name of Main Carer:

Name of Clinical Nurse Specialist:

G.P:

Practice Name: Practice Telephone Number:

Referral Date: 1st visit – Date: H@H leaflet given - Date: Nurse availability given – Date:

Diagnosis: Reason for referral:

Medication: Oral CSCI PRN

PPOC Date: PPOD Date: CHC Date:

LCP Date: DNAR Date: CAD Date:

RIP Date:

Place:

Photocopy permitted for professional use Moving and Handling Risk Assessment:

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Is the patient totally independent Has a Risk Assessment been done by the DN Y/N Smoking: Pets: Complex Situations: Equipment: Care Package: Route & Parking: Access/Exit of property: e.g. do we need a key/can someone let us in?

Appendix 6: Willen Hospice Internal Department Referrals INTERNAL DEPARTMENTAL REFERRALS 

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NHS NO                                          

ICARE NO             

TITLE 

FIRST NAME 

SURNAME 

 

ETHNICITY 

REFERRING DEPARTMENT 

REFERRING DATE 

 

                DAY HOSPICE                                                               PATIENT & FAMILY SERVICES                                                 

                YOUNG PEOPLE’S SUPPORT SERVICE                      CHAPLAIN                  

                HOSPICE AT HOME                                                     CNS 

                LYMPHOEDEMA                                                          PSYCHOLOGY (PRINT AND SEND) 

VERBAL CONSENT OBTAINED FROM     

ADDITIONAL COMMENTS 

 

CONTACT DETAILS

Author: Kim Purkiss Review Date:

Appendix 7 – Lymphoedema Referral Form

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LYMPHOEDEMA SERVICE REFERRAL FORM This Lymphoedema Clinic is for cancer and related treatments, diagnosed primary lymphoedema and life

limiting disease. Please note: a) A patient with suspected primary lymphoedema must be referred to vascular services prior to referral to Willen Hospice. b) A patient with active cellulitis requires treatment prior to referral. Refer to www.thebls.com/consensus.php for guidance. c) Doppler to be completed for lower limb swelling prior to appointment at the clinic as compression therapy will be required.

Please complete all sections. Mark those that are not applicable as N/A.

The following must be excluded prior to referral:

Undiagnosed new or re-occurent malignancy Yes / No Please attach relevant correspondence and summaries, plus current medication.

DVT: Yes / No Vascular obstruction: Yes / No Low Albumin: Yes / No Heart Failure: Yes / No

PATIENT DETAILS

Surname: First Names: Gender: Male /

Female

Hospital Number:

Address:

Post

Code:

Tel: Mobile:

Marital Status:

D.O.B:

Age: Ethnic origin:

1st Language choice:

Next of Kin: Name: Address:

Post Code:

Tel: Relationship:

Patient’s GP: Name and Address:

Tel:

NHS No:

REFERRAL DETAILS

Referrer Name and Title:

Organisation: Tel:

Has consent been given? Yes / No. If No, state why:

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Is patient well enough to attend clinic? Yes / No Signature:

Date:

Are any other Professionals involved? (Please name all concerned.)

Hospital Consultant:

District Nurse:

Clinical Nurse:

Oncologist:

Specialist: Other:

Patient Name: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DOB: . . . . . . . . . . . . . . . Hospital No: . . . . . . . . . .

FOR PRIMARY LYMPHOEDEMA (Results of diagnosis from vascular consultant must be

attached.)

Site of Lymphoedema: Duration:

Vascular Consultant: Date of Lymphoscintography:

DOPPLER ASSESSMENT

ABPI: Left leg: Right leg:

Date completed: By whom: Profession:

PAST MEDICAL AND SURGICAL HISTORY (Required for all referrals)

Heart Failure: Yes / No

Vascular disease: Yes / No

Obesity: Yes / No

Renal Disease: Yes / No

Chronic Skin disorder: Yes / No

DVT in past 6 months: Yes / No

Thyroid Disease: Yes / No

Rheumatoid Arthritis: Yes / No

Hypertension: Yes / No

Diabetes: Yes / No

Mobility problems: Yes / No

BMI:

FOR CANCER RELATED SWELLING

Affected area: Disease Management:

Active / Palliative

Duration/Date of onset: Reoccurrence of

previous malignancy? Yes / No

Disease Status: Diagnosis (to include metastases): Date of diagnosis:

Is patient aware of diagnosis? Yes /

No

Treatment, past and current: Surgery: Date:

Radiotherapy: Date:

Chemotherapy: Date:

Hormonal Treatment:

Date started:

No. of lymph nodes removed:

No of positive Nodes:

Version 2. Issued March 2013 Author: K. Iseton Review date: March 2016

30

Comments / Any other conditions:

Allergies / Sensitivities: History of Cellulitis: Antibiotics prescribed: Date of last episode: Any other relevant information:

FOR OFFICE USE ONLY

Date received: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of 1st appointment: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Author: K. Iseton Review date: March 2016 Version 2. Issued March 2013