Referral form and criteria to Specialist Occupational Therapy

SPECIALIST PALLIATIVE CARE OCCUPATIONAL THERAPY
REFERRAL FORM
Name
Date of Birth
Address
York Hospital No:
NHS No:
Next of Kin/Carer
Address (if different)
Consultant
Ward
Primary Care Contacts
***NB Patient must be
registered with a S&Y GP ***
Tel no:
Diagnosis
Tel no:
Background information including relevant past medical history
Reason for referral to specialist OT (NB Must meet criteria for specialist intervention see below)
Is patient aware of this referral? Y/N
Is patient known to Specialist Palliative Care Team?
Y/N
Referred by: (please print name and contact details)
Date
Contact phone no:
Signed:
Please return form to: Specialist Palliative Care Team Office, The Lodge ℅ St Leonard’s Hospice
185 Tadcaster Road, York YO24 1GL
Tel: 01904 724476 Fax: 01904 777049
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REFERRAL CRITERIA FOR SPECIALIST PALLIATIVE CARE O.T.
Telephone queries are welcome to discuss possible referrals
1) Patient must have life threatening or life limiting disease and who require specialist support for
complex physical and psychological needs that cannot be met by existing OT service alone.
2) Patient must have a GP in the Selby and York locality of the North Yorks and York Primary
Care Trust
3) Patient requires input from specialist Palliative Care OT (needs are not able to be met by other
OT services)
Referrals are only accepted from Health and Social care professionals on a written referral form
Examples of possible intervention which specialist OT could offer:
• A functional rehabilitation programme to enable patients deal with the complex difficulties
associated with their condition (e.g. fatigue, anxiety, breathlessness, pain, balance or memory
problems)
• Assistance to participate in activities related to study or work, including advice regarding return
to work
• Lifestyle management advice to cope with fatigue or altered level of independence
• Advice regarding coping strategies for dealing with cognitive dysfunction
• Facilitating psychological adjustment to loss of function
• Support and education to carers resulting from patients changing level of functional and/or
cognitive ability
• Assessment for and prescription of standard self propelling wheelchair
Exclusion criteria
Patients requiring general OT assessment of functional performance and intervention as required
In these circumstances referral should be directed to existing OT services:-
• For patients in hospital contact the OT team linked to the consultant the patient is under
• For outpatients either
o Local Authority OT service (phone council the patient pays their council tax to) or
o OT service linked to Virtual Wards
• North / East – tel (72)1122 )
• South / West / Central – tel (72)4625)
• Selby – tel 01904 (72)4276 )
Please use existing
Community Outreach referral
form and contact locality team
for forms and fax numbers
Owners: Carole White – Clinical Specialist Palliative Care OT Tel 01904 (72) 4476
Brian Teskey-King OT Team Leader and Specialist Palliative Care OT, Selby Locality
Dated Sept 2010
These criteria will be regularly reviewed and revised as appropriate in the light of experience
C:\Documents and Settings\paul.twigg\Desktop\PDF\Policies\Referral to OT form criteria for specialist OT flow chart 09 10.doc

FLOW CHART FOR REFERRALS TO SPECIALIST PALLIATIVE CARE OT
Patient presents with functional
performance problems requiring
OT assessment and possible
intervention
Refer to OT service (either
linked to Virtual Ward or Local
Authority / Social Services)
Occasionally patients
specialist needs can be
identified immediately
Patient has complex rehabilitation requirements over and
above what can be met by Virtual Ward or Local Authority OT
service and meets the criteria for referral to the Specialist
palliative care team
Contact Specialist Palliative
Care OT Carole White to
discuss possible referral and if
accepted, complete a written
referral form
N.B. Not all Palliative Care Patients require Specialist Palliative Care
OT intervention.
C:\Documents and Settings\paul.twigg\Desktop\PDF\Policies\Referral to OT form criteria for specialist OT flow chart 09 10.doc