COMMUNITY HEALTH SERVICES & GERIATRIC SPECIALTY SERVICES REFERRAL

Community Health Services provides a wide range of professional services in the community and in client homes, depending on the client’s assessed care need and urgency of need. Services may be short-term if your client is recovering from a procedure or condition or long-term if the client needs ongoing care. For further details of services provided, please visit www.viha.ca/hcc/services/

Geriatric Specialty Services includes specialized care for seniors who are generally complex with unstable, often co-morbid psychiatric and/or medical issues, frailty and/or functional decline. Referrals for a Geriatric Psychiatrist or Geriatrician must come from a physician. The specialists do work within an interprofessional team to assess and manage complex psychiatric and medical conditions for elderly clients. Please refer to the Pathways site for details on inclusion/exclusion criteria.

How to Complete this Form:

Reason for Referral:

Describe: •   Indicate client need with specific medical, functional, cognitive and/or social concerns with some timelines of when these changes started occurring •   Describe the urgency of client situation •   For Geriatric Specialty Service referrals, indicate the specific clinical need that requires assessment and/or treatment recommendations

Additional for Geriatric Specialty Services only :

Provide: •   Information on any diagnostics and assessments completed to rule out other causes for clinical presentation •   Information on any pharmaceutical treatments already trialed

Relevant/Pertinent Medical History:

Indicate: •   Recent or new diagnosis •   Relevant medical history that impacts current clinical presentation •   If MOST (Medical Orders for Scope of Treatment) order has been developed, include copy •   Palliative Diagnosis: include PPS score

Clinical Features:

Describe: •   Behavioral features: Aggression (verbal or physical), wandering, socially inappropriate (include intensity and frequency (eg. episodic to daily occurrence) •   Mood Disturbance or Anxiety including intensity and duration (eg. episodic to daily occurrence) •   Cognitive changes (e.g. memory, executive functioning, word finding, processing, etc.) •   Falls and/or physical weakness •   Pain issues (describe intensity and frequency)

Home Situation:

Provide any information on: •   Safety issues, including environmental and social risks set up •   Abuse, neglect or self-neglect concerns •   Caregiver status •   Capacity to continue living in current environment

Collateral Information:

•   A current medication list including over the counter medications, supplements and vitamins and allergy list is REQUIRED •   For Geriatric Specialty Service referrals, labs REQUIRED: CBC and diff, Na,K,creat, eGFR, Ca++,albumin, +/-protein, GGT, AST +/- Alk phos, TSH, Serum B12 •   CT Head if done previously

Subject: