FOR RESIDENTIAL FACILITIES

Transcription

1 AGED CASP 1a - APMHS REFERRAL ACASP 1a AGED PERSONS MENTAL HEALTH SERVICE REFERRAL FOR RESIDENTIAL FACILITIES Surname:. Rapid UR:. Given names:... D.O.B.:. Sex: Address: Phone:.. Medicare Number:. Date of admission to facility:. To be filled in by referring agency / service. PLEASE COMPLETE ALL AREAS. REFERRAL SOURCE: Name of facility: Phone:. DATE OF REFERRAL:.. Address: Fax:.. Name of referrer:.. Contact details:. Is the GP (or MO) aware of the referral? No. If NO, why not?.. Yes Is the person being referred aware of the referral? No. If NO, why not? Yes Is the person known to have had past contact with Mental Health Services? No Unsure Yes If yes, provide details:. KEY STAKEHOLDERS: Next of kin / primary carer: Relationship: Address:.... Phone:.. GP: Address:.. Phone:.. Guardian involved: No Yes Name.. Phone:.. Other agencies involved: No Yes Specify:.. PRESENTING PROBLEM: Please describe the principle complaint, giving a clear description of behaviours, onset, course, duration, triggers, stressors and symptoms. Please detail any previous management plans / strategies and responses to same..... Regional Triage Service for all enquiries Phone PLEASE FAX REFERRAL TO: Please refer to the APMHS Referral Flow Chart and Guidelines for further details

2 WHAT IS BEING REQUESTED AS AN OUTCOME OF THIS REFERRAL? Consultation Behavioural Intervention Assessment and Ongoing Management Education INVESTIGATIONS (IF AVAILABLE PLEASE ATTACH COPIES OF RESULTS) Type Ordered Abnormalities detected? Type Ordered Abnormalities detected? No Yes No Yes No Yes No Yes FBE U&E s TFT LFT CXR CT BRAIN Other: (Specify ) MSU BGL B12 & Folate ESR ECG MRI Other: (Specify) KNOWN CONDITIONS: None known Diabetes Recurrent UTI s Acquired brain injury Epilepsy Thyroid disorder Angina Falls Past history Suicidality Chronic pain Hypertension Past history Depression CVA Mobility problems Past history Psychosis Delirium Myocardial infarct Past history Anxiety Dementia Parkinson s disease Other : PRESCRIBED MEDICATION: (LIST OR ATTACH COPY OF MEDICATION CHART/SHEET) Name Dose Frequency Name Dose Frequency Compliance: Low (not compliant) Medium (not sure) High (definitely compliant) Known adverse reactions / sensitivities: No Yes Specify:. RISK ISSUES: Please record any risk issues that are apparent Page 2 of 5

3 BEHAVIOURS CONSCIOUSNESS ASSESSMENT CAPACITY PSYCHIATRIC SYMPTOMS COGNITIVE IMPAIRMENT MANAGABILITY PHYSICAL RISK ISSUES CURRENT MANAGEMENT AND/OR CONCERNS OTHER COMMENTS SCREENING ASSESSMENT Settled - stable Settled - unstable Fluctuating Anxious Agitated Aggressive Violent / Assaultive Manic Withdrawn Unpredictable Confused Disoriented Absconding Non-compliant / resistive Alert Drowsy Fluctuating Drug/Alcohol affected Sedated Unconscious Able to be assessed Unable to be assessed Depressed Mood Elevated Mood Fluctuating Mood Disorganised behaviour Poor concentration Hallucinations Delusional beliefs Not evident Mild Moderate Severe No current management problems Fluctuating management problems Moderate management problems Difficult to manage Extreme management problems Unknown awaiting assessment Nil Mild co-morbidity Moderate co-morbidity Severe co-morbidity Acutely medically unwell Discussed with resident Discussed with family Discussed with staff Discussed with GP Referred to specialist / other COMMENTS... REFERRER S SIGNATURE:. DATE: NOTE: If this is an EMERGENCY call and inform the Duty Worker PLEASE FAX TO: Page 3 of 5

4 GUIDELINES FOR REFERRING TO AGED PERSONS MENTAL HEALTH SERVICES The Aged Persons Mental Health Service (APMHS) provides specialist psychiatric assessment and treatment to aged persons with a mental illness who live in the Loddon/ Campaspe/ Southern Mallee regions. The service has two essential components; A community based service that provides home based comprehensive assessments and treatment for those aged persons in the community experiencing a mental illness. This includes services to residential facilities and Acute and Subacute services where the team provides specialist aged mental health expertise. The service utilises a case management style of care provision with support from; Consultant Psychiatrists, Psychiatric Registrar, Psychiatric Nurses, Neuro-Psychologist, Social and Welfare worker. The service is closely aligned with the Aged Care Assessment Service to assist in a range of Aged Care issues. A purpose built 10 bed inpatient facility (the Marjorie Phillips Unit) that is located at the Anne Caudle campus in Bendigo. This facility is equipped to provide treatment of acute mental health issues. Services are provided to: People aged 65 and older; and Who have, or appear to have, a mental illness; and or Exhibit behaviour of moderate to severe significance related to dementia; In some cases indicated by clinical assessment, APMHS will provide service to people under 65 years of age who exhibit symptoms of degenerative diseases associated with ageing such as early onset dementia or Alzheimer's disease. In order to help the APMHS triage/intake service respond to referrals in a timely and prioritised manner, guidelines have been developed as indicated on the flowchart over-page. Consideration should be given to the following issues before Referral to APMHS: As it is more effective and efficient to direct referrals to the triage service of Bendigo Psychiatric Services on than to contact the mental health clinicians who work in the various localities, please direct all referrals to this area of the service. Referrals from GPs, residential facilities, hospitals, and other health or community services should be made on the referral documentation supplied with these guidelines. Note: If your service does not have these forms, contact our administration (see below) and we will ensure that you receive these. All sections of the referral document should be completed. Services seeking to make referrals are requested to seek the consent of the person they wish to refer (or their carer / family / guardian as appropriate). Staff of residential services are requested to discuss the referral with the clinical management of their service, as well as the referee s GP, before contacting Triage NOTE: If the matter is an EMERGENCY, please call and request assistance. If possible, have as much of the information required on the referral form as is available, to assist the triage service to respond efficiently. CONTACT DETAILS FOR APMHS: TRIAGE SERVICE Phone (24 hrs) Fax ADMINISTRATION Phone (8:30am 5:00pm. Mon-Fri) Fax MAIL PO Box 126, Bendigo. Victoria NOTE: If the matter is an EMERGENCY, please call APMHS directly on (24 hrs) and request assistance. Page 4 of 5

5 Concerns regarding a resident s mental health or behaviours identified by staff through reporting, observation or assessment Is there a RISK issue? Residential Service to complete it s own risk assessment, Assess possible reasons for presentation PHYSICAL Eg. Infection, trauma, constipation, pain, hypoglycaemia, fatigue, known medical conditions.. ENVIRONMENTAL Eg. Noise, clutter, temperature, recent changes, new resident.. GUIDELINES FOR REFERRAL TO AGED PERSONS MENTAL HEALTH SERVICE BY RESIDENTIAL SERVICES Is the presentation attributable to the above? NO YES Discuss with GP regarding blood screening or baseline investigations 1. Discuss with GP regarding treatment options or referral to appropriate service 2. Strategise environmental change / manipulation. ABNORMALITIES DETECTED? YES NO To action a referral, complete the APMHS Referral Form and fax to, or call, the Regional Triage Service: Fax: (03) Tel: Discuss with GP and resident s carer/family regarding referral to APMHS If the matter is an EMERGENCY, call APMHS via the Regional Triage Service on And request assistance Page 5 of 5