GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 1 of 11
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Patient Identification
Referral Destination
Referral to Rehab: (Please check one)
HTSD / Regular stream LTLD/slowstream Either (Receiving facility to determine)
Referral to Complex Continuing Care (CCC) (For LTLD / slowstream rehab, select within Rehab Category above)
If Faxed Include Number of Pages (Including Cover): _________ Pages
Estimated Date of Rehab/CCC Readiness: DD/MM/YYYY
Patient Details and Demographics
Health Card #: Version Code: Province Issuing Health Card:
No Health Card #: No Version Code:
Surname: Given Name(s):
No Known Address:
Home Address: City: Province:
Postal Code: Country: Telephone: Alternate Telephone:
No Alternate Telephone:
Current Place of Residence (Complete If Different From Home Address):
Date of Birth: DD/MM/YYYY Gender: M F Other__________ Marital Status:
Patient Speaks/Understands English: Yes No Interpreter Required: Yes No
Primary Language: English French Other ___________________________
Primary Alternate Contact Person:
Relationship to Patient (Please Check All Applicable Boxes): POA SDM Spouse Other_________
Telephone: Alternate Telephone: No Alternate Telephone:
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 2 of 11
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Patient Identification
Secondary Alternate Contact Person: None Provided:
Relationship to Patient: POA SDM Spouse Other _________ (Please Check All Applicable Boxes)
Telephone: Alternate Telephone: No Alternate Telephone:
Responsibility for Payment:
Insurance: ______________________________________ N/A:
OHIP Federal Government IFH (Interim Federal Health Grant)
Inter-provincial Insurance Plan Insured/Self Pay Other Payment Sources
WSIB Uninsured/Self Pay Unknown
Preferred accommodation:
Ward Semi private Private Other (specify): _______________________________________
For CCC Only - Co-Payment Discussed With: Patient Other__________________
Rehab/CCC Population Requested:
ABI Amputee Burns Cardiac Chronic Ventilation General/Medical
Geriatric MSK Neuro Oncology Respiratory Rehab Spinal Cord
Stroke Trauma Transplant Other _________________________________________________
Current Location Name: Current Location Address:
City: Province: Postal Code:
Current Location Contact Number: Bed Offer Contact Name: Bed Offer Contact Number:
Medical Information
Primary Health Care Provider (e.g. MD or NP) Surname: Given Name(s):
None
Allergies: No Known Allergies Yes --- If Yes, List Allergies:
Infection Control: None MRSA VRE CDIFF ESBL TB Other (Specify):__________________________
Admission Date: DD/MM/YYYY Date of Injury/Event: DD/MM/YYYY Surgery Date: DD/MM/YYYY
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 3 of 11
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Patient Identification
Nature/Type of Injury/Event:
Primary Diagnosis:
Current Medical Issues:
Past Medical History:
Attach the following:
Medication: MAR
Lab Work: If indicated, send most recent lab work (e.g. Haemoglobin, white blood cell count, lytes, creatinine)
Height: Weight:
Is Patient Currently Receiving Dialysis: Yes No Peritoneal Hemodialysis Frequency/Days: ____________________
Location: ________________
If Dialysis Centre is located off-site from rehab/CCC, indicate how patient will access Dialysis Centre:
Family drives Volunteer drives Wheel-Trans Other____________________
Is Patient Currently Receiving Chemotherapy: Yes No Frequency: ____________________ Duration:________________
Location: ___________________
Is Patient Currently Receiving Radiation Therapy: Yes No Frequency: ____________________ Duration:________________
Location:__________________
Concurrent Treatment Requirements Off-Site: Yes No Details:
Prognosis: Improve Remain Stable Deteriorate Palliative Palliative Performance Scale:________ Unknown
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 4 of 11
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Patient Identification
Advanced Medical Directives:
Services Consulted: PT OT SW Speech and Language Pathology Nutrition Other____________________
Pending Investigations: Yes No Details:
Frequency of Lab Tests: _________________ Unknown: None:
Study Medications: Yes No Details:
Respiratory Care Requirements
Does the Patient Have Respiratory Care Requirements? Yes No -- If No, Skip to Next Section
Supplemental Oxygen: Yes No Ventilator: Yes No
Target 02 Sat _________ % Intermittent Oxygen ___________ L/min Constant Oxygen ________L/min
02 at rest ___________ L/min 02 at exercise_______ L/min
Special Oxygen Equipment/Human Resources required? (e.g. rebreather, Optiflow, specialized resources of Respiratory Therapist):
No Yes (if Yes, please specify): ________________________________________________________________________________
Breath Stacking: Yes No Insufflation/Exsufflation: Yes No
Tracheostomy: Yes No Cuffed Cuffless Type: Size:
Suctioning: Yes No Frequency:
C-PAP: Yes No Patient Owned: Yes No
Bi-PAP: Yes No Rescue Rate: Yes No Patient Owned: Yes
No
Additional Comments:
IV Therapy
IV in Use? Yes No -- If No, Skip to Next Section
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 5 of 11
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Patient Identification
IV Therapy: Yes No Central Line: Yes No PICC Line : Yes No
Name of IV Medication:
Hearing/Vision
Hearing:
Intact, can hear routine conversation Intact, with hearing aid Reduced hearing Completely impaired
American Sign Language
Vision:
Intact Intact with visual aid Visual field deficit Double vision Completely impaired
Swallowing and Nutrition
Swallowing Deficit: Yes No Swallowing Assessment Completed?: Yes No
Type of Swallowing Deficit Including any Additional Details:
TPN: Yes (If Yes, Include Prescription With Referral) No
Enteral Feeding: Yes No Tube Type: ______________ Specify Formula Type & Rate of Feeds: _______________________
Diet: Regular Kosher Diabetic Renal Low Sodium Other (specify): ____________________________
Falls
Does Patient Have a History of Falls? Yes No -- If No, Skip to Next Section
If yes, specify: home/community hospital
History & Frequency: Frequent Rare Intermittent
Reason for most recent fall(s):
Balance Vision Strength Fatigue Decreased insight/judgment Unknown
Other (list):
Skin Condition
Surgical Wounds and/or Other Wounds Ulcers? Yes No -- If No, Skip to Next Section
1. Location: Stage:
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 6 of 11
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Patient Identification
Dressing Type: Frequency:
(e.g. Negative Pressure Wound Therapy or VAC)
Time to Complete Dressing: Less Than 30 Minutes Greater Than 30 Minutes
2. Location: Stage:
Dressing Type: Frequency:
(e.g. Negative Pressure Wound Therapy or VAC)
Time to Complete Dressing: Less Than 30 Minutes Greater Than 30 Minutes
3. Location: Stage:
Dressing Type: Frequency:
(e.g. Negative Pressure Wound Therapy or VAC)
Time to Complete Dressing: Less Than 30 Minutes Greater Than 30 Minutes
* If additional wounds exist, add supplementary information on a separate sheet of paper.
Continence
Is Patient Continent? Yes No -- If Yes, Skip to Next Section
Bladder Continent: Yes No If No: Occasional Incontinence Incontinent
Bowel Continent: Yes No If No: Occasional Incontinence Incontinent
Ostomy: N/A Yes Type/brand and care/products required _____________________________________________________
Ability to care for ostomy: Independent Total care Requires supervision
Pain Care Requirements
Does the Patient Have a Pain Management Strategy? Yes No -- If No, Skip to Next Section
Controlled With Oral Analgesics: Yes No
Medication Pump: Yes No
Methadone: Yes No
Epidural: Yes No
Has a Pain Plan of Care Been Started: Yes No
Communication
Does the Patient Have a Communication Impairment? Yes No -- If No, Skip to Next Section
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 7 of 11
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Patient Identification
Communication Impairment Description:
Cognition
Cognitive Impairment: Yes No Unable to Assess -- If No or Unable to Assess, Skip to Next Section
Details on Cognitive Deficits:
Has the Patient Shown the Ability to Learn and Retain Information: Yes No -- If No, Details: ____________________
Cognitive Status (Complete
Table Below)
Not Tested Intact Impaired
Orientation
(specify):
Attention (specify):
Able to follow instructions (specify):
Memory (short term) (specify):
Memory (long term) (specify):
Judgment (specify):
Insight (specify):
Frustration Tolerance (ABI only) (specify):
Other (specify):
MMSE Score: ______
or
MoCA Score: ______
If did not/unable to complete, please explain:
Rancho Los Amigos Cognitive Scale at present: (ABI only): ___________________________________
Delirium: Yes No -- If Yes, Cause/Details: ___________________________________________
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 8 of 11
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Patient Identification
History of Diagnosed Dementia: Yes No
Behaviour
Are There Behavioural Issues? Yes No -- If No, Skip to Next Section
Does the Patient Have a Behaviour Management Strategy: Yes No
Behaviour: Need for Constant Observation Verbal Aggression Physical Aggression Agitation Wandering
Sundowning Exit-Seeking Resisting Care
Other
Restraints -- If Yes, Type/Frequency Details : ____________________
Level of Security: Non-Secure Unit Secure Unit Wander Guard One-to-one
Social History
Discharge Destination: Multi-Storey Bungalow Apartment LTC
Retirement Home (Name):
Accommodation Barriers: Unknown
Smoking: Yes No Details:
Alcohol and/or Drug Use: Yes No Details:
Previous Community Supports: Yes No Details:
Discharge Planning Post Hospitalization Addressed: Yes No Details:
Discharge Plan Discussed With Patient/SDM: Yes No
Current Functional Status
Patient Goals (Please Indicate Specific, Measurable Goals):
Participation Level:
(Specify): On average, patient is able to participate in ______ therapy sessions / day, _____times / week for _______minutes / session
Sitting Tolerance: More Than 2 Hours Daily 1-2 Hours Daily Less Than 1 Hour Daily Has not Been Up
Transfers: Independent Supervision Assist x1 Assist x2 Mechanical Lift
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 9 of 11
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Patient Identification
Ambulation: Independent Supervision Assist x1 Assist x2 Unable
Number of Metres: _______________
Stairs: Independent Supervision Assist x1 Assist x2 Stair Lift/Glider
Weight Bearing Status:
Left: U/E L/E
Full As Tolerated Partial ______% Toe Touch Non Date expected to be weight-bearing _____________
DD/MM/YYYY
Right: U/E L/E
Full As Tolerated Partial ______% Toe Touch Non Date expected to be weight-bearing ____________
DD/MM/YYYY
Limbs:
Left: U/E impairment L/E impairment Aid(s) Required: ________________________________________
Right: U/E impairment L/E impairment Aid(s) Required: __________________________________________
Bed Mobility: Independent Supervision Assist x1 Assist x2
Activities of Daily Living
Describe Level of Function Prior to Hospital Admission (ADL & IADL):
Current StatusComplete the Table Below:
Activity Independent
Cueing/Set-up or
Supervision
Minimum
Assist
Moderate
Assist
Maximum
Assist
Total Care
Eating:
(Ability to feed self)
Grooming:
(Ability to wash face/hands,
comb hair, brush teeth)
Dressing:
(Upper body)
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 10 of 11
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Patient Identification
Activity
Independent
Cueing/Set-up or
Supervision
Minimum
Assist
Moderate
Assist
Maximum
Assist
Total Care
Dressing:
(Lower body)
Toileting:
(Ability to self-toilet)
Bathing:
(Ability to wash self)
Special Equipment Needs
Special Equipment Required? Yes No -- If No, Skip to Next Section
HALO Orthosis (including splints, slings)
Bariatric - If Yes, Please Describe Equipment Needs:_______________________________________________________________
Other:
Pleuracentesis: Yes No Drain: Yes No - If Yes, Type Details:___________________________________
Paracentesis: Yes No Drain: Yes No - If Yes, Type Details:___________________________________
Need for a Specialized Mattress: Yes No Negative Pressure Wound Therapy (NPWT): Yes No
Rehab Specific
AlphaFIM® Instrument
Is AlphaFIM® Data Available: Yes No -- If No, Skip to Next Section
Has the Patient Been Observed Walking 150 Feet or More: Yes No
If Yes Raw Ratings (rate levels 1-7)
Transfer: Bed, Chair_________ Expression_________ Transfers: Toilet________
Bowel Management_________ Locomotion: Walk_________ Memory__________
If No Raw Ratings (rate levels 1-7)
Eating_______ Expression_________ Transfers :Toilet________
Bowel Management________ Grooming________ Memory_______
Projected:
FIM® projected Raw Motor (13): FIM® projected Cognitive (5):
Help Needed:
GTA Rehab Network Integrated Acute Care to
Inpatient Rehab & Complex Continuing Care (CCC) Referral Form
This referral form is in compliance with the Provincial Referral Standards and
includes supplemental information for referral to Rehab/CCC programs in the GTA
.
GTA Rehab Network Integrated Acute Care to Inpatient Rehab/CCC Referral Form
Alternate Level of Care Resource Matching & Referral Business Transformation Initiative (ALC RM&R BTI)
Page 11 of 11
Attachments
Details on Other Relevant Information That Would Assist With This Referral:
Please Include With This Referral:
Admission History and Physical
Relevant Assessments (Behavioural, PT, OT, SLP, SW, Nursing, Physician)
All relevant Diagnostic Imaging Results (CT Scan, MRI, X-Ray, US etc.)
Relevant Consultation Reports (e.g. Physiotherapy, Occupational Therapy, Speech and Language Pathology
and any Psychologist or Psychiatrist Consult Notes if Behaviours are Present)
Completed By: Title: Date: DD/MM/YYYY
Contact Number: Direct Unit Phone Number:
AlphaFIM® and FIM® are trademarks of Uniform Data System for Medical Rehabilitation (UDSMR), a division of UB Foundation Activities, Inc. All Rights Reserved.
The AlphaFIM® items contained herein are the property of UDSMR and are reprinted with permission.
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