For Professionals

Pathway Management

All admissions are managed according to your progress, pathway duration and funding approval. The pathway and duration of stay is determined initially by the referrer and funding authority.

Depending on the admission pathway, regular review meetings will be held to discuss your nursing care or rehabilitation pathway.

Within the first two weeks of admission, you and your family members, or representative will be invited to attend our Meet and Greet. This provides an opportunity for you and loved ones to meet the treatment team and ask any questions you may have or express your expectations of your placement here.

Marillac offers various pathways, that have been designed to suit each resident's presenting level of needs:

Enhanced Maintenance Therapy (EMT) pathway
Neuro rehabilitaion pathway
Palliative care pathway
Prolonged Disorder of Consciousness (PDOC) pathway

Referral Form

Referrer Details

Date of Referral:

Please enter todays date:

Name of Referrer:

Please enter your name.

Contact Tel:

Please enter your phone number.

Organisation:

Please enter your organisation.

Job Title:

Please enter your job title.

Email:

Please enter your email.

Referral Pathway:

Continuing Health Care

Level 2 Rehab

(D2A) Discharge to assess/Stepdown

Please select the appropriate box.

Patient Information

Name:

Please enter the patients name.

Telephone:

Please enter the patients telephone number.

DOB:

Please enter the patients date of birth.

Home Address:

Please enter the patients address.

NHS Number:

Please enter the patients NHS number.

Email:

Please enter the patients email.

Gender:

Please enter the patients gender.

Privately Owned

Rented

Supported Accommodation

*Homeless

Please select the appropriate information.

*If patient is homeless, please provide details here of any referrals made, for example: social worker, homeless team/housing etc. to allow our team to follow up:

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Please confirm if discharge destination has been identified:

Yes

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Immigration Status:

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*if Yes, please provide details:

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Living Circumstance

Alone

Family

Friends

Please tick the appropriate box.

Current Location:

Inpatient

at Home

Other

Please tick the appropriate box.

Current Address of Patient

Please enter the current address of the patient.

Ward Name:

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Ward Contact Number:

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Person to Contact / NOK:

Please fill in the appropriate information.

Relationship to Patient:

Please fill in the appropriate information.

NOK Address:

Please enter the NOK address.

NOK Tel:

Please enter the NOK telephone number.

NOK Email:

Please enter the NOK email.

Do they live with the referred person:

Yes

Please tick yes or no.

Has patient consented to information regarding referral being shared with this person:

Yes

Please tick either yes or no.

GP Name & Address:

Please fill in the appropriate information:

Language (s) Spoken:

Please fill in the appropriate information.

GP Contact Number:

Please fill in the appropriate information.

Interpreter Required:

Yes

Please tick yes or no.

Clinical Summary / Presentation

Diagnosis:

Please fill in the appropriate information.

Relevant Medical History (including past medical history):

Please fill in the appropriate information.

Allergies or Adverse Reactions:

Please fill in the appropriate information.

Presenting Condition(s) Including Date of Onset

Please fill in the appropriate information.

Previous Physical & Cognitive Function: - including mobility & cognitive/ADLs

Please fill in the appropriate information.

Funding

Please confirm that funding authority is aware of this referral:

Yes

Please tick yes or no.

Pathway:

NHS

Social Care

Self-Funding

Please tick the appropriate box.

Please confirm funding has been approved. (CHC/D2A/Rehab):

Yes

Please tick yes or no.

Name of Funding Authority:

Please fill in the appropriate information.

Commissioning Officer / Team / Brokerage Team / Neuro Navigator / Case Manager / Contact Person:

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Contact Telephone:

Please fill in the appropriate information.

Contact Email:

Please fill in the appropriate information.

Contact Job Title:

Please fill in the appropriate information.

Contact Organisation:

Please fill in the appropriate information.

Breathing

Presenting Condition(s) (e.g. COPD, asthma, sleep apnoea)

Please fill in the appropriate information.

Relevant Information: (including equipment)

Please fill in the relevant information.

Tracheostomy

Cuffed

Uncuffed

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Date of Initial Insertion:

Please enter the appropriate information.

Other Relevant Details:

Oxygen:

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Type/Size:

Please enter the appropriate information.

Date Last Changed:

Please enter the appropriate information.

Ventilator:

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Litres Prescribed:

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Nutrition

Presenting condition(s) e.g. dysphagia, gastroparesis, GERD etc:

Please enter the appropriate information.

Oral Intake

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Modified Consistency (Please give details of IDDSI fluid/diet levels)

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Assisstance with feeding

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Risk Feeding

Invalid Input

Please give details:

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Please give details:

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Please provide details of any: food intolerances and specific types of dietary requirements for example: Halal, Kosher etc.

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Enteral

Invalid Input

PEG

PEJ

RIG

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Date Last Change:

Invalid Input

Date of Insertion:

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Weight:

Please enter the appropriate information.

Height:

Please enter the appropriate information.

BMI:

Please enter the appropriate information.

MUST:

Please enter the appropriate information.

Other Relevant Details:

Invalid Input

Continence

Continent

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Needs assistance to toilet/commode

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Incontinent of Bladder

Invalid Input

Incontinent of Bowel

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Catheter

Invalid Input

Type/Size:

Invalid Input

Last Changed:

Invalid Input

Other relevant details:

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Tissue Visability

Skin Intact:

Yes

Please select yes or no.

Moisture Lesions:

Yes

Please select yes or no.

Area(s):

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Pressure Ulcer:

Yes

Please select yes or no.

Area(s):

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Grade:

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Other Wounds (please specify):

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Waterlow Score:

Invalid Input

Other Relevant Details Including Equipment:

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Communication

Presenting condition(s) e.g., aphasia, motor speeh disorder etc

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Please select the appropriate option:

Able to communicate without assistance

Unable to communicate

Requires assistance for communication

Please select the appropriate option:

Other relevant details (including low/high tech AAC, visual aids etc):

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Cognition

Please select the appropriate option(s):

Difficulty understanding and processing information

Memory problems

Low awareness state

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Other relevant details:

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Mental Capacity

Please select the appropriate option:

Full

Variable

None

DOLS in place

Please select the appropriate option.

Additional Information:

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Urgent DOLS application required?

Yes

Please tick yes or no.

Date of latest mental capacity assessment:

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Medication:

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Other specialist information (i.e. diabetes management, haematology, oncology, rheumatoid conditions):

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