Restorative Care Pathway Application

Things to discuss with client and family prior to applying:

The Restorative Care Pathway is a person-centered, goal-oriented approach that empowers participants to optimize their full independence.
Goals are achieved through a range of time-limited, intensive interventions led by health professionals and carers.
The pathway is a collaborative, multidisciplinary support, including families and support networks. It focuses on ‘doing with’ rather than ‘doing for’ the individual.

Referrer Details

Date

Name of Referrer

Title

Agency

Phone

Email

Participant Details

Participant Name

Date of Birth

Phone

Email

AC Number

Address

Street address

Suburb

State

Postcode

Representative / Supporter Details

Primary Representative / Supporter Name

Primary Representative / Supporter Phone

Secondary Representative / Supporter Name

Secondary Representative / Supporter Phone

Application Consent

Has the participant received Restorative Care in the last 12 months

Yes, 8-week pathwayYes, 16-week pathwayNo

Provide further details

Consent for referral

YesNo

Provide further details

Consent for continued communication and participation throughout pathway. Including but not limited to initial assessments, mid-way reviews, feedback and exit planning.

YesNo

Provide further details

Application

Brief overview of reason for referral to the Restorative Care Pathway.
This may include details of recent hospital admission, new diagnosis, physical or psychological deterioration, recent fall, change to lifestyle, change in family dynamics, change to living circumstances etc.

What are some of the client’s goals in commencing this program?
This may include an approach to help slow functional decline, reduce the risk of falls, promote better health outcomes, boost confidence, alleviate depression, foster social engagement, reduce feelings of loneliness and social isolation.

How long is this program expected to run for and why?
8 or 16 weeks. Please provide documentation of why 16 week program would be more beneficial to achieve clients goals e.g. d/c summary, GP report, Allied Health report, Nursing Assessment

Does the client fall into any of the subcategories below?

Provide further details

Identify preferred supports the client wishes to be included throughout pathway.
Family members and social networks

*Please upload any supporting documents to MAC with application

This is the final copy and ready to be sent through to the Restorative Care Pathway Team

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