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Barwon Health / Practitioner Portal

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  • Modify Practitioner/Practice Details
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  • Transition Care Program
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Transition Care Program

Home/ Transition Care Program

Transition Care Program

Thank you for completing this referral for a Transition Care Residential or Transition Care Domiciliary Bed.

Once received, the Transition Care Program Administration Officer will be notified of your referral via email.

Once the client has been ACAS'd and Delegated they will be placed on the TCP Waitlist. When TCP have capacity to review the client, you will be notified when that will occur.

All mandatory fields must be completed for the referral to be generated.

Should you have any questions about the progress of your referral, please email admintcprcp@barwonhealth.org.au as our preferred method of contact.

"*" indicates required fields

DD dash MM dash YYYY
Are you requesting a residential or home based bed?

Client being referred

DD dash MM dash YYYY
Is the patient Aboriginal or of Torres Strait Islander descent?
Is an interpreter required?
DD dash MM dash YYYY
DD dash MM dash YYYY

Next of kin contact details (must be able to be contacted during business hours).

Transition Care Goals

Complete restorative processes to enable the recipient to enter RAC at the optimum level of functioning:
Maintain current level of functioning/independence
Case management support to assist client/family make long term care arrangement
Psychosocial support to assist with the transition to RAC
When TCP residential program is the discharge destination TCP goals may include

Physio goals

To maintain optimal functional transfers and mobility
To maintain strength and endurance
Involvement in individual and group sessions with physio/AHA
Prescription of gait aids

Occupational Therapy goals

Encourage participation in ADLs such as attending meals in dining room
Assess for and coordinate home modifications
Formal cognitive assessments

Social Goals

Support client family through process of making long term care arrangements

Nursing Goals

Maintain skin integrity
Maintain appropriate level of continence
Cognitive and behavioural management strategies

Speech Therapy goals

Ongoing assessment and monitoring of dysphagia
Prescription and monitoring of appropriate modified diets

Dietician goals

Monitoring and assessment of appropriate dietry requirements

Special Equipment

Is special equipment required for the patient?

Diet

Diet
Texture
Please indicate with I, A or D.

Pre morbid function (four weeks prior to recent problems)

Indoor mobility*
Transfers*
Personal care*
Continent urine
Continent faeces

Current function

Indoor mobility*
Transfers*
Personal care*
Continent urine
Continent faeces

Current cognition

Have there been any concerns about the patient's current cognition?*
Has there been any formalised cognitive testing?*
Alert*
Orientated*
Does the patient have short term memory loss?*

Premorbid cognition

Current Behaviour/Mood

No issues:*
Uncooperative*
Disruptive*
Aggressive*
Depressed*
Anxious*
Has additional staffing been required?*
Wanders*

Has referral been consented by patient/representative?*

Payment Responsibilty

  • Add New Practitioner or New Practice
  • Modify Practitioner/Practice Details
  • Electronic Image Viewing and Reports
  • Inpatient Rehabilitation Centre
  • Transition Care Program

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General Enquiries: 03 4215 0000

In an emergency, always call 000 first

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  We, Barwon Health, acknowledge the Traditional Owners of the land, the Wadawurrung people of the Kulin Nation. We pay our respects to their Elders past, present and emerging.

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