Download 05 Fast Track Care Domains - West Suffolk Clinical Commissioning

Fast Track – Care Domains
Name: _____________________________ DOB: ___________ NHS: ____________________
GP/GP Surgery:
NOK Details (if appropriate):
Name:
Relationship:
Address:
Post Code:
Telephone:
The Ipswich and East Suffolk Clinical Commissioning Group and the West Suffolk Clinical Commissioning Group can
only accept a Fast Track Referral with the completed documents:
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Consent Form
Fast Track Tool
Fast Track Care Domains
Mental Capacity Assessment and Best Interest Decision (if appropriate)
Once completed please send a copy of these documents to Continuing Healthcare; either by email or fax.
Email: [email protected]
Fax: 01473 770202
Fast Track Tool completion – prompts:
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Details of Diagnosis
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Details of Prognosis
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Is there evidence of a rapid deterioration? Yes / No. Please provide evidence
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Is the person entering a terminal phase? Yes / No. Please provide evidence
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Care package required: Care package at home / Care Home / how many carers are needed per visit?
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End of life care plan included? Yes / No.
Care Domains
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In this section you will need to describe the actual needs of the patient.
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Give examples of frequency, intensity, duration and the type of intervention required.
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Where a Care Domain is felt to be complex or intensive; give examples.
Form Completed By:
Name & Signature :
Role:
Organisation / Team:
Contact Number (including Mobile / Bleep):
Ipswich and East Suffolk Clinical Commissioning Group
West Suffolk Clinical Commissioning Group
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Fast Track – Care Domains
Name: _____________________________ DOB: ___________ NHS: ____________________
Care Domains
Assessment
Behaviour Compliant with care?
Any challenging behaviour?
Patterns/triggers/frequency?
Cognition Evidence of cognitive impairment e.g. difficulties
in retrieving short-term memory?
Orientated to time and place?
Awareness of basic risks?
Psychological and Emotional Needs Overt moods? Tearful?
Responds to reassurance?
Anti-depressant prescribed?
Hallucinations?
Communication –
Sight/Hearing/speech impairment?
Clearly communicate needs verbally?
English first language?
Require assistance/special efforts to
communicate?
Able to reliably answer closed questions?
Needs anticipated due to familiarity with the
individual?
Mobility –
Able to weight bear? Assistance needed? Able
to change own position?
Equipment aids?
History of falls?
Nutrition / Food and Drink –
Is the patient able to take adequate food and
drink? Do they require prompting, supervision or
feeding?
Note: Give details if NBM – associated to end of
life care. Give details if Artificial feeding – such
as N/G, Peg, Sub Cut Fluids, IV Fluids.
Weight loss/Gain? Supplements?
Ipswich and East Suffolk Clinical Commissioning Group
West Suffolk Clinical Commissioning Group
Page 2 of 4
Fast Track – Care Domains
Name: _____________________________ DOB: ___________ NHS: ____________________
Continence (Urinary and Faecal) Is the patient incontinent of urine and/or faeces
and how is this managed?
Bowel management regime
History of UTIs?
Skin Integrity –
Pressure Risk Assessment Tool and Score:
Wounds? Pressure ulcers? Skin conditions?
Treatment required?
Interventions in place i.e. mattress/cushion?
Breathing –
Normal Breathing? Manage own airway?
Oxygen therapy? Nebulisers/ inhalers?
Shortness of breath?
Tracheotomy?
Recurrent chest infections?
Medication, Pain / Symptom Control -–
Individual Compliant?
Who administers medication? Self-medicating?
Orally or by other route? Routine non- complex?
Pre-emptive medications in place/use?
Medication for symptom control?
Syringe driver – please note what medications
are in the syringe driver and who is managing
this.
Altered States of Consciousness –
Epilepsy / Seizures / Faints / Stroke / Vacant
episodes?
Medications?
Frequency?
Other –
E.g. Any night needs?
In receipt of a current care package?
Ipswich and East Suffolk Clinical Commissioning Group
West Suffolk Clinical Commissioning Group
Page 3 of 4
Fast Track – Care Domains
Name: _____________________________ DOB: ___________ NHS: ____________________
Proposed Care Plan / Care Needs over 24 hours
Time
Care Required
Frequency
e.g. 45 minutes
between 07:00 – 09:30
Single carer input for: assistance onto commode, empty catheter bag, strip wash and
dress/shower, mouth care, repositioning/transfer out to chair. Medication support. Offer
food/drink.
Every day
Additional Information: e.g. Family involvement / Input from other services
Ipswich and East Suffolk Clinical Commissioning Group
West Suffolk Clinical Commissioning Group
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