POAC Service Requisition

POAC SERVICE REQUISITION
Aged Care Facility Referral Process:
- Confirm POAC funding approved
- Referrers make arrangements directly with facilities to discuss requirements and acceptance of care. Visit the Eldernet site HERE for a list of vacancies in the area.
- Contact POAC to confirm facility acceptance, or to discuss where there are difficulties in finding suitable placement.
This POAC referral should not be used for any non-acute situation. The following specifically are excluded:
- Extension of existing POAC services - contact the POAC team referral@poac.co.nz or (09) 535 7218. Or if weekend/after hours and urgent, contact the service provider directly.
- Patients who are existing home support clients, unless discussed and referred directly by NASC
- Patients who have been assessed as requiring long-term aged residential care and are yet to decide on a facility
- Respite care for carer stress (contact NASC for priority assessment which should be completed for P1 status within 2 days)
I, the referrer, confirm ALL of the following:*

The patient and/or family has been fully informed and consented to this referralThe patient is eligible for publicly funded health services in New ZealandThe patient would otherwise require ACUTE HOSPITAL ADMISSION
Patient domiciled district*

AucklandCounties ManukauWaitemata
Date*

DayMonthYear
Date
Service request*

Rest HomePrivate HospitalSecure Dementia Unit (with letter confirming assessment)Home SupportsHome Nursing Visit
Patient has been assessed as requiring secure dementia level of care and supporting documentation (geriatrician or GP) attached/emailed (referral cannot proceed if supporting documentation not attached).*

YesNo
Sorry, we are unable to proceed for the following reason:

This option is only available where a level of care assessment has been completed and patient has been confirmed as requiring secure dementia level of care.

Please call POAC to discuss (09) 535 7218
Is this referral related to an injury under ACC that can be covered under ACC705 referral?*

YesNo
Please refer to ACC for home-based support services. Use ACC705 form for for Te Whatu Ora referral, complete form, select Geneva as provider, email or fax form directly.
Is the patient currently receiving any home-based support services/home help?*

Not currently receiving any home support servicesSupport package is in place but existing provider is unable to provide urgent increased supports (this must be discussed with NASC prior to referring to POAC)
Residential care facility preference:*

Booking confirmed at facility indicated below (POAC to confirm funding approval)Booking pending at facility indicated below
Residential Care Facility
Provider email contact
if known
Nursing Agency*
Home Care Provider*
Waiheke Resident Confirmation*

Yes - patient is Waiheke Island residentNo - please change the Home Care Provider in above field
REFERRER INFORMATION
Referred by*

General PracticeHospitalHospiceUrgent CareSt JohnResidential CareOther
Designation*

DoctorRegistered NurseNurse PractitionerSocial WorkerOther
Name of referrer/contact person*

First NameLast Name
Referring organisation*
Ward*
Contact phone*
Contact email*
To receive email confirmation of referral submission
GP Informed*

GP/Practice has been informed and consented and can be contacted as requiredGP/Practice has been informed and consented but not available to visit
GP Practice Email
PATIENT DETAILS
Patient name*

First NameLast Name
NHI*
Date of Birth*

DayMonthYear
Gender*

MaleFemaleOther
Ethnicity*
Patient address*
This service is not currently available for Waiheke Island residents
Home access
Please describe any issues to accessing home, directions, dogs or entry instructions
Living situation*

Lives aloneLives with partnerLives with family/friendsNo fixed abodeBoarding facilityResides in Aged Residential CareOther
Patient contact details*
NOK name(s) and contact details*
Best contact person and phone number(s)
Best contact person to discuss supports

PatientNOK/EPOAOther
CLINICAL HISTORY
Patient GP name and phone *
If different from referring clinician
Current diagnosis and reason for referral*
Relevant active medical problems*
List of medications/known allergies
Patient is on medications requiring regular follow up by GP during this stay and GP has been advised (referral cannot proceed if GP not advised)*

YesNo
Concerns/risks*

None applicableFunctional declineFalls riskMild cognitive impairmentDeliriumDementia (please state behaviours)Wanders or risk of wanderingMental health concerns (please state)Isolation required (please state reason)Patient required a watch during hospital admission but has been without watch for 48 hours without incident (referral cannot proceed if patient still requiring watch)Patient weight >130kgRequires a bariatric bed (for ARC referrals only)Other
Mental health summary*
Please describe any relevant mental health history, current health state or concerns, including any risk to self or carer
Mobility

Fully independentWith assistanceMobilising with use of stick/cane/crutchMobilising with walker/frameWheelchairFully bed boundOther
Continence*

No known issuesBladder incontinentBowel incontinentCatheterStomaOther
SERVICES REQUIRED
Home Support Services

(Excludes Shopping or Housework, not POAC funded)
Services required:

Showering assistanceDressingMeal preparationMedication prompting (This does not include medication administration of any kind (including topical medicated creams which will require a referral for nursing visit)Wellness checkOther
Initial funded date*

DayMonthYear
Date
Final funded date*

DayMonthYear
Date
Total days/nights funded*
How many days in total will be required?
Total days*
MAXIMUM OF 7 DAYS FUNDED UNDER POAC. IF EXTENDED PERIOD REQUIRED, PLEASE CONTACT POAC referral@poac.co.nz
Number of hours required daily*
How many hours of care will be required each day. This may be an estimate and can be split across multiple visits. This will be discussed with patient and/or NOK. Minimum of 1 hour per visit.
Total maximum number of hours funded by POAC for this episode*
Tasks required at each visit*
Please describe in detail the tasks required at each visit (e.g showering assistance, meal preparation, medication prompting)
Plan following POAC*

Short term only, no further requirementsNASC assessment required post/during POAC episode (NASC referral must be submitted)Long Term Provider (date known and scheduled to start)Taikura Trust follow up requiredOther
Plan following POAC care
It is important a clear and confirmed plan is in place following the POAC-funded care. Please indicate the plan of care following POAC completion. (e.g. NASC assessment, DHB supports, family taking home, return to normal care). Ensure where required that a NASC referral has been urgently submitted.
Intravenous Therapy
- All medication is to be supplied

- Daily dose medication only

- Signed prescription and discharge summary (or clinical notes) to be faxed to POAC 09 535 7154 or attached to referral
Antibiotic name
Dosage
Dosage frequency*
PICC Line*

YesNo
Line in situ*

YesNo
Check List*

Signed prescriptionHospital discharge summary or clinical notesMedication supplied to patient
Additional information
Transport to facility

Independently arranged transportationAmbulance (hospital will arrange)Ambulance (POAC to arrange)TaxiMobility transport (wheelchair)Other
Pick up location*
Access for ambulance crew*
Please provide details and instructions for collection, including any stairs, pets or other access issues
Patient will travel in ambulance by:*

StretcherChair
Weight of patient*
Requirement to book appropriate ambulance crew
Upload document (or email to referral@poac.co.nz

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Disclaimer: POAC takes no responsibility for omissions of/or incorrect information. It is the responsibility of the referrer and receiving facility to ensure transfer of accurate information.
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POAC SERVICE REQUISITION

REFERRER INFORMATION

PATIENT DETAILS

CLINICAL HISTORY

SERVICES REQUIRED

Home Support Services

Intravenous Therapy