The Myton Hospices - Refer a patient online today

Section A

Service type and location request

I am*

I am a healthcare professional referring a patient
I am a patient or family member referring to: Therapeutic Day / Living Well

Please select which service is required*

Please note: Therapeutic Day, Living Well and Fatigue and Breathlessness are day therapies.

Self referral

Patients may self-refer to our Therapeutic Days (Day Unit) and the Living Well Programme.

A family member or friend can complete this for you with your consent.

I wish to be referred to*

You can select multiple

Therapeutic Day
Living Well

Preferred location*

Coventry
Rugby
Warwick

Self referral / referring a loved one*

I am referring myself
I am referring someone else

I confirm I have the consent of the patient to submit a referral on their behalf:*

Yes
No

Is the patient happy for us to contact them*

Yes
No

Does the patient consent for us to contact outside agencies who are involved with their care e.g. GP, Community Nurse?*

Yes
No

Your details

Your first name*

Your surname*

Your telephone number

Your mobile number*

Your email

Patient details

Patient first name*

Patient surname*

Patient address line 1*

Patient address line 2

Patient city/town*

Patient date of birth*

Patient telephone number

Patient mobile number*

Patient NHS number

Patient email

Patient gender

Male
Female
Transgender

GP details

GP first name*

GP surname*

GP practice*

GP address line 1

GP address line 2

GP city/town

GP postcode

GP telephone number

Persons Diagnosis (including current treatment):*

Other relevant medical history:

Does the patient have any goals you hope the Living Well Project will support you to achieve?

Is the patient previously been known to the Day Unit?*

Yes
No

When was the patients last visit?

What is the patient hoping to gain from attending the Day Unit (from therapy days)?

Is there any other information you feel would be useful for us to know before we meet you?

Inpatient Medical Bed

Myton has two inpatient units in Warwick and Coventry. Both have teams of nurses, doctors and other health care professionals. Admission will be considered for any patient aged 18 years or over, with specialist palliative care needs due to advanced, progressive, life limiting disease. The patient should be registered with a Coventry or Warwickshire GP to access the inpatient unit beds. The Myton Hospices do not provide long term care.

Preferred location*

Coventry
Warwick
Either

Reason for Referral

Please detail below essential information to outline the patient’s need;*

e.g. Uncontrolled symptoms, complex emotional/psychosocial /spiritual support required.

Please include details of main symptoms/severity and what treatment plan is currently in place*

e.g. syringe driver, summary of medications, type of pain

Urgency of referral*

Same day (emergency admission)
Within two working days
Within five working days

If same day (emergency admission) – please do not continue this form please call:

Monday – Friday, 8am - 4pm please call Referrals and Discharge on 01926 838889

Anything outside of these hours please call Warwick Myton Reception on 01926 492518 and ask for an Inpatient Unit Senior Nurse or follow the voicemail instructions.

You will not be able to progress any further with this referral.

Inpatient Nurse Led Bed

Short description of service

Does the patient referred have a Coventry or Rugby GP?*

Yes
No

Does the patient referred meet the criteria for fast-track funding?*

Yes
No

Has CHC funding has been agreed?*

Yes
No
Unsure

Reason for Referral

The patient cannot be cared for in their own home or are not able to be cared for in an alternative place of nursing care due to their specialist palliative nursing and/or supportive care needs?*

Yes
No

The patient referred does not require medical assessment or regular medical intervention i.e. they should be medically stable for discharge if in hospital or the hospice?*

Yes
No

Is the patient in their final days or few weeks of life and have a DNACPR in place?*

Yes
No

Respite Bed

The Inpatient Unit at Warwick Myton Hospice offers respite admissions for patients who are aged 18 and over, have a terminal illness and are registered with a GP in Coventry & Warwickshire.

Is the patient clinically stable?*

Yes
No

Is the patient highly dependent on their carer in the home setting?*

Yes
No

Reason for Referral

Please detail below essential information to outline the patient’s need;*

Myton at Home

Many people want to have choice over where they are cared for in the last weeks and days of life. Often people wish to stay in familiar surrounds, in their own home.

Is the patient registered with a Rugby, Warwick or Leamington GP?*

Yes
No

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

Please call our referral team where we will try to direct you to an alternative service:

Monday – Friday, 8AM - 4:00PM please call Referrals and Discharge Clinical Nurse Specialist on 01926 838889

Saturday - Sunday – 9AM - 5:00PM please call our Myton at Home team: For Rugby: 01788 551516 / Warwick: 01926 838814

You will not be able to progress any further with this referral.

Is the patient known to a community nursing team?*

Yes
No

Please ensure that you make a community nurse referral as well as completing this form.

Is the patient in their last 2-4 weeks of life?*

Yes
No
Unsure

Reason for Referral

To facilitate hospital / hospice discharge*

Yes
No

To prevent hospital/hospice admission*

Yes
No

Personal Care

You can select multiple here.

Day
Night

Respite Sit*

Yes
No

Psychological care*

Yes
No

Urgency of contact*

Same day response
Within 48 hours
Less than one week

If same day response – please do not continue this form please call:

Monday – Friday, 8am - 4pm please call The Myton at Home team on Rugby – 01788 551516 / Warwick 01926 838814

Anything outside of these hours please call Warwick Myton Reception on 01926 492518 and ask for an Inpatient Unit Senior Nurse or follow the voicemail instructions.

You will not be able to progress any further with this referral.

Visits required?*

You can select multiple here.

Days
Evenings
Nights

Does the patient have a syringe driver in situ?*

Yes
No

Equipment currently in place?*

You can select multiple here.

Please state what other equipment currently in place*

Continence details?*

You can select multiple here.

Continent
Pads
Commode
Catheter

Nutrition needs?*

Mobility*

Unaided
With aid
Bed bound
Hoist

Therapeutic Day

Our Day Units offer a welcoming, relaxed, yet stimulating atmosphere providing patients with an opportunity to meet and talk to others who are in a similar situation to themselves and access to a structured therapeutic programme of activities.

Preferred location*

Coventry
Rugby
Warwick

Patient transport*

The patient will attend the Day Unit by own transport
The patient will require a volunteer driver (will need to be able to access the care unaided, patient’s requiring oxygen will require an ambulance)
The patient requires an ambulance due to requiring assistance with mobility to access a car and/or they require oxygen

Living Well

The Living Well Programme is aimed at enabling people to identify their most significant concerns and priorities, providing a range of support to help manage the changes in their life and to enable them to focus on the things that are meaningful to them.

Preferred location*

Coventry
Rugby
Warwick

Patient diagnosis (including current treatment)*

Relevant co-morbidities / past medical history*

Other health and social care professionals known to this person. Please state names and contact details.*

Does the patient have a ReSPECT form?*

Yes
No

Fatigue and Breathlessness

The FAB programme takes place in the Day Unit on each of the Myton sites and is designed to support people who have a life limiting illness which causes fatigue and breathlessness.

Preferred location*

Coventry
Rugby
Warwick

Primary diagnosis underlying participant’s breathlessness*

MRC Dyspnoea Scale Score (if known)

Relevant co-morbidities/past medical history*

What do you hope the participant will gain from this course?*

Does the patient use oxygen?*

Yes
No

How many of litres of oxegen will the patient need per minute?*

Please ensure that the patient is aware they will need to bring Oxygen for a two hour programme (as well as their travelling time)

Does the patient have a ReSPECT form?*

Yes
No

I confirm the participant is aware of this referral, the need to bring their own ambulatory oxygen and provide their own transport*

Yes

Lymphoedema

Our Lymphoedema Service is based at Warwick Myton Hospice and serves both Myton and community patients of Coventry, Rugby and South Warwickshire.

Which part of the body is affected?*

Lymphoedema treatment to date

Cancer diagnosis*

Cancer treatment*

Known metastatic sites (if applicable)

Other medical history*

Medication*

Does the patient have any allergies or sensitivities?*

Yes
No

Please tell us more about the patients allergies or sensitivities*

What is the most recent CPR decision*

Attempt CPR
Do not attempt CPR
No decision made

Is the patient attend the clinic or is the patient housebound?*

Patient can attend clinic
Patient is housebound

The patient may qualify for a home visit. Please continue the form.

Any requirements specify to patient (e.g. hearing/sight/care needs)*

Refer a patient

Section A

Self referral

Your details

Patient details

GP details

Inpatient Medical Bed

Reason for Referral

If same day (emergency admission) – please do not continue this form please call:

You will not be able to progress any further with this referral.

Inpatient Nurse Led Bed

Reason for Referral

Respite Bed

Reason for Referral

Myton at Home

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

You will not be able to progress any further with this referral.

Please ensure that you make a community nurse referral as well as completing this form.

Reason for Referral

If same day response – please do not continue this form please call:

You will not be able to progress any further with this referral.

Therapeutic Day

Living Well

Fatigue and Breathlessness

Lymphoedema

The patient may qualify for a home visit. Please continue the form.

Section B

Next of Kin

Section C

Other Healthcare Professionals involved

Section D

Section E

Section A

Self referral

Your details

Patient details

GP details

Inpatient Medical Bed

Reason for Referral

If same day (emergency admission) – please do not continue this form please call:

You will not be able to progress any further with this referral.

Inpatient Nurse Led Bed

Reason for Referral

Respite Bed

Reason for Referral

Myton at Home

Unfortunately, this service only supports patients under a Rugby, Warwick or Leamington GP.

You will not be able to progress any further with this referral.

Please ensure that you make a community nurse referral as well as completing this form.

Reason for Referral

If same day response – please do not continue this form please call:

You will not be able to progress any further with this referral.

Therapeutic Day

Living Well

Fatigue and Breathlessness

Lymphoedema

The patient may qualify for a home visit. Please continue the form.

Section B

Next of Kin

Section C

Other Healthcare Professionals involved

Section D

Section E

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