Hampshire Hospital Discharge Meals on Wheels Referral Form

Hampshire Hospital Discharge Meals on Wheels Referral Form

This is a referral form for Hampshire Hospital Discharge Meals on Wheels.

Referrals must be received by 8:30am for same day delivery. If you are requesting a start date for this service on the same day as discharge, please ensure that the patient will return home before 11.15am.

Clients can receive daily meals on wheels fully funded for 7 days under this service (meals are delivered between 11.15am to 2.15pm).

Clients are able to stay on the service for longer if the client is able to pay for their meals beyond the initial fully funded period.

Provision of personal data: we cannot provide a service without a minimum amount of personal information. These sections of the form are mandatory. Please ensure that you have the client’s permission to share their data, if you are completing the form on their behalf. Please see our full privacy statement at the end of this form, or give us a call on 0330 2000 103.

Before you start

You can save the form at any time and return to it later by clicking the save button at the end of each page. If you do not want to create an account, you can skip this and either copy the link to your form, or provide an email address to receive a link to your draft form. Remember to click submit once you have completed the form.

If you have any issues completing this form, please email: hampshire@hils-uk.org

Client's details (person receiving the service)
ELIGIBILITY FOR MEALS ON WHEELS: please ensure that the client meets at least one of the following criteria, and tick the appropriate box(es):
Please tick to confirm that:
Please tick to confirm that:
This scheme is intended to support people who may not otherwise receive help following a hospital discharge. Please tick to confirm that the client meets at least ONE of the following: Would struggle to cook or shop for themselves; Has a carer or relative who needs a break from cooking or shopping; Is feeling physically or mentally unwell; Has difficulty accessing food; Has limited or no support network; Is financially vulnerable or receiving financial benefits
Name

First NameLast Name
Address Line 1
Address Line 2
Town
County
Postcode
Telephone (main)
Telephone (other)
Email
example@example.com
Date of birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Gender
Ethnicity
We are required for monitoring purposes to ask the ethnicity of all our clients to ensure the equality of our service. Please select the client’s ethnicity from the list above
Is the patient being discharged on Pathway 0 or Pathway 1?
If meals on wheels support was not available, would the patient be discharged on Pathway 1?
Hospital
NHS Number
Date of admission

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date of discharge

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Reason for admission
Client Consent - please tick to confirm that:

Client Support Organisations

Sharing information about other services or organisations which support our clients, will help us to keep clients safe. This information will only be used to protect clients’ vital interests. Please provide this below:
Name of home care provider
Home care telephone number
Name of community alarm provider
Community alarm telephone number
GP Surgery
GP Telephone number
Other support service / professional
Other telephone number

Client Support Contacts

It is very important that we have details of other people who we can contact if we have any concerns regarding the client’s health, safety, finances, or wellbeing.

We can provide a better service if we have an emergency contact who is available between 11.15am and 2.15pm to answer the phone if required.

This is in case a client is not at home when we attempt to deliver, we cannot find the client, and we are concerned for their welfare. We understand that not all contacts will be able to perform all support functions, so please tick the boxes to indicate who we should contact in which situation. If you can provide more than two contacts, please email these to us along with your form. Where possible please provide a mobile phone number.

If you do not have any contacts, please call our friendly team who may be able to help.
First Support Contact
Name

First NameLast Name
Phone (primary)

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Please tick where applicable
Relation to client
Second Support Contact
Name

First NameLast Name
Phone (primary)

Area CodePhone Number
Phone (other)

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityCounty

Postcode
Please tick where applicable:
Consent:

Referrer's (Your) Details
Name

First NameLast Name
Role or relationship to client
Organisation
Department/Team/Agency (if applicable)
Phone number
Email (we will confirm receipt of this referral to this email address)
example@example.com
How did you hear about HILS?
If you have selected 'other,' or if you would like to provide specific information about how you heard about HILS, please provide details below. It is extremely helpful to share this information with us, so that we can better reach the people who need our services.
Please confirm that:

Delivery, Access Details, and Risk
How would the client like us to access their home, or deliver their meal? (e.g. would the client like us to use a keysafe, bring their meal into the lounge, or meet them at the door)
Can our staff help by doing any of the following when delivering the meal?
Keysafe code (if applicable)
Keysafe location (if applicable)
Door entry code (for main building)
Should we always use a keysafe to access the client's home?
Any other access information (for instance, if the property is hard to find, is up flights of stairs, has limited parking, etc.)
Risk
Is there anything that could pose a risk to our staff when visiting the client's home? (for instance, others in the household, dogs that don’t like visitors, is the client a smoker, drug or alcohol dependent, history of aggressive/ offensive behaviour etc.)

Meals on Wheels Service Details
Start Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearPlease avoid requesting a start date for this service on the same day as discharge unless you are sure that the patient will return home before 11.15am
End Date (only required if meals are needed for a short time)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please select the days that a hot meal and dessert is required:

PLEASE PRESS SUBMIT
How will your information be used?

Your personal data will only be used to deliver a safe, caring, and tailored service that meets your individual needs. We will never share your data without your consent unless we believe that you may be in danger or that your wellbeing is at risk. In this case, we would only share the information necessary to help you stay safe and well, and only with the proper authorities (e.g. police, ambulance) and/or your emergency contacts. While it is in our care, your data will be kept securely and only viewed by authorised HILS staff. All team members are trained in how to keep your data safe and your rights as a data subject, we do not use any automated decision-making or data profiling processes – meaning all decisions regarding your service are made by humans.

What are your rights?

HILS comply with the General Data Protection Regulation 2016, meaning that we are committed to keeping your personal data safe and will always respect your rights as a data subject. These rights are:

The right to be informed and to limit data processing – this means that we need to tell you about how we are using your personal data and will only use it in the way we describe above. If we want to use your personal data for anything else, we will always tell you and ask for consent if necessary. You have the right to disagree with the way we process your data and to ask for this to be changed, these requests would be reviewed on a case by case basis.

The right to access, ask for corrections, and to delete personal data – this means you can ask to see all the data that we hold on you, to ask for data to be changed and/or deleted from our records.

The right to data portability – this means that you can request for us to provide you with all the personal data we hold on you in a format that you can take with you (e.g. if you want to take your information to another service provider).

To find out more about your rights and how HILS processes personal data, please see our Privacy Notice on our website at: www.hils-uk.org/privacy-policy/. You can also contact us via email on data@hils-uk.org or call 0330 2000 103 and ask for the HILS Data Protection Officer.

Click submit below to complete the form, otherwise we will not receive your referral.
Should be Empty:

Client's details (person receiving the service)

Client Support Organisations

Referrer's (Your) Details

Client Wellbeing

Delivery, Access Details, and Risk

Risk

Meals on Wheels Service Details

Dietary Information