Long-term Care Complex Behaviour Referral Date: Client Information Client Name: PHN: Date of birth Format: mm/dd/yyyy Age: -None-Arrow Lakes Hospital, Nakusp (Minto House)Ashcroft Hospital (Jackson House)Bastion Place, Salmon ArmBrandt's Creek Mews - GlenmoreBrocklehurst Gemstone Care CentreBrookhaven CBDU - West KelownaBrookhaven, West KelownaCariboo PlaceCastleview Care Centre, CastlegarColumbia Garden Village, InvermereColumbia House, InvermereColumbia View Lodge, TrailConnect Lake CountryCoquihalla Gillis House, MerrittCottonwoods, KelownaCreekside LandingCrest View Care VillageDavid Lloyd Jones, KelownaDeni House Residential Services-Williams LakeDr. F.W. Green Memorial Home, CranbrookFischer Place/Mill Site Lodge (SCHC), 100 Mile HouseForestview, Clearwater (Dr. Helmcken)Gateby Care Facility, VernonGlenmore Lodge, Kelowna (NEW! As of Feb 15, 2017)Hardy View Lodge (Sunshine Manor), Grand ForksHaven Hill Retirement Centre, PentictonHenry Durand Manor, GoldenHeritage Square (Bethany Home), VernonHeron GroveHillside Village, Salmon ArmJoseph Creek Care VillageKamloops Seniors Village, KamloopsKimberley Special Care Home, KimberleyKootenay Street VillageLake Country Lodge, WinfieldLakeview Lodge, West KelownaMariposa Gardens, OsoyoosMcKinney Place, OliverMission Creek Landing, KelownaMonashee Mews, LumbyMount Ida Mews, Salmon ArmMountain Lake Seniors CommunityMountain View, GoldenMountainview Lodge, LillooetMountainview VillageMt Cartier Court, RevelstokeNelson Jubilee Manor, NelsonNoric House, VernonOrchard Haven (SSHC), KeremeosOtherOverlander RC, KamloopsParkview Place, EnderbyPiccadilly Seniors CommunityPine Acres, West KelownaPine Grove Lodge, KamloopsPleasant Valley Manor, ArmstrongPolson Residential Care, VernonPonderosa Lodge, KamloopsPoplar Ridge, TrailRidgeview Lodge, KamloopsRidgewood Lodge, PrincetonRocky Mountain Village, FernieRose Wood Village, TrailSilver Kettle Village, Grand ForksSlocan Community Health CentreSpring Valley Care Centre Ltd. (formerly Windsor Manor)Summerland Extended Care, (Dr Andrew Pavilion) SummerlandSummerland Seniors Village, SummerlandSun Pointe Village, KelownaSunnybank Care Home, OliverSwan Valley Lodge, CrestonTalarico Place, CastlegarThe Hamlets at PentictonThe Hamlets at Vernon (Vernon)The Hamlets at Westsyde - KamloopsThree Links Manor, KelownaTrinity Care Centre, PentictonVictorian Hospital (Community Residential Care), KasloVillage at Mill Creek (replace Stillwater) KelownaVillage at Smith Creek, West KelownaVillage by the Station, PentictonWestview Extended Care, PentictonWilliams Lake Seniors Village, Williams Lake Facility Name of Clinical Lead at the Facility/Unit: First Name Last Name Name of Person Completing the Referral: First Name Last Name Details Phone: Most Responsible Physician / Nurse Practitioner: Has MRP / NP been notified? YES NO Was the person hospitalized in the last 3 months for this behaviour? Yes No Mental Health Diagnosis: Medical Diagnosis: Recent Changes Recent Changes in medication? Yes No Describe: Details Reason for Referral (describe behaviour and when did it start): What RISKS does the behaviour present? Roaming (wandering) Imminent physical risk (delirium, illness, safe mobilizing) Suicidal Kinship relationship (risk of harm to others, staff) Self-neglect, safe driving, substance abuse Other… Is an AGG Alert in place? Yes No Have you consulted the BC BPSD Algorithm? Yes No Has a P.I.E.C.E.S. Worksheet been completed? Yes No Changes to the RAI Outputs (CAPs, outcome scales) Changes to the RAI Outputs (CAPs, outcome scales): SUMMARIZE P.I.E.C.E.S. WORKSHEET FINDINGS BELOW: P - Physical (medications, pain/discomfort, mobility, infections, illnesses): E - Emotional (mood disorders, depression, delusions/hallucinations, personality disorders): C - Capabilities (decline of ADLs, IADLs): E - Environment (over/under stimulation, relocation, change in routine): S - Social (life story, social network, cultural heritage): Questions What seems to make the behaviour worse? What seems to make the behaviour better? Is a psychiatrist involved? Yes No Name of the psychiatrist: Is Mental Health services involved? Yes No Name of MH Clinician: Is Acquired Brain Injury services involved? Yes No Name of Case Manager: Please provide your email address in order to receive a copy of this Referral: Please complete all mandatory fields before submitting CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
