Updated on16/11/2011
working together for health & well-being
Bath & North East Somerset’s Exercise Referral Scheme Passport to Health Service
Making Bath & North East Somerset an even better place to live, work and visit 1
Contents Introduction Overview of the scheme Referral Guidelines Operating protocol for Referrers Operating protocol for Referral Exercise Professionals Activity Pathways Help us to help you
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Appendices Referral form Irwin & Morgan Risk Stratification Tool
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Introduction This guide has been produced in response to the National Quality Assurance Framework (NQAF) for Exercise Referral Systems (2001) and Professional and Operational Standards for Exercise Referral: The Joint Consultative Forum of Medical Royal Colleges, The Faculties of Health & Sport and Exercise Medicine, The Chartered Society of Physiotherapy and the Fitness Sector of the United Kingdom (2011). The guide aims to provide all professionals involved with the Passport to Health Scheme a point of reference when referring to the programme, ensuring a standardised and consistent service is offered equally to all of its users. Updates to material included in this guide will be issued by the Project Officer - Health, who will request that you take responsibility for replacing the out-ofdate information with the new material. Receiving this guide and adhering to all guidelines, procedures and protocols provides accreditation to the Passport to Health referral service.
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Overview of the Scheme The Passport to Health Service has developed and expanded to offer a range of physical activity interventions based at local leisure facilities and in other community settings. In October 2011, the Healthy Lifestyle Referral Hub launched, enabling anyone wishing to access stop smoking, healthy eating, weight management, lifestyle advisor and physical activity services to do so via one single referral form. Consequently, any referrals to the Passport to Health programmes go directly through the hub and are then processed by the Council’s Project Officers – Health. All programmes that form the Passport to Health Service aim to target sedentary individuals who also present with one or more other health related risk factor(s). The objective being to assist them in increasing their activity levels to help reduce their risk of coronary heart disease (CHD), and other diseases, and help combat the symptoms of mild to moderate depression and post-natal depression (PND). Individuals referred to the service are assessed and, where eligible, are offered a 12 week programme of exercise based on their needs. Costs for activities are heavily subsidised and all clients will attend pre- and postexercise assessments to establish the impact the service has had on their activity levels and health risk. Any healthcare professional with access to an individual’s medical notes, who is able to complete the referral form in full, is able to make an official exercise referral. All other professionals are advised to recommend the programme by completing the top section of the hub referral form. Medical consent will then be requested by the Project Officers – Health. All referral consultants responsible for the safe and effective management, design and delivery of client exercise programmes are qualified in GP Exercise Referral and registered with the professional body REP (Register of Exercise Professionals) at Level 3 or 4.
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Referral Guidelines
Referral Criteria Appropriate Referrals *Sedentary / Inactive 60 mins moderate intensity activity per week.
Inappropriate Referrals** Unstable angina, hypertension, diabetes
Aged from 16 years upwards
Post MI 16 weeks, not attending Phase III Rehab
All patients must be clinically stable
Unstable or acute heart failure.
Overweight/Obese
Acute Psychosis st
Family History of CHD (1 degree relative)
Acute viral illness
Smoker signed up to Support to Stop service
Advanced osteoporosis, osteoarthritis or severe back pain
Type 2 Diabetes Uncontrolled tachycardia 100bpm at rest. BP/Cholesterol Risk Resting BP >180/100mmHg Mild to moderate depression Pregnancy Post-natal depression Claudication Financial barriers Palliative Care Social barriers Physical/mental restrictions Carer commitments
Please Note: Exercise referral instructors are not trained to accept the above high risk conditions as they do not hold additional qualifications to support these groups. Clients falling into the above categories would, therefore, not be appropriate and must not be referred.
*The GPPAQ may also be used to assess physical activity levels. Those patients scoring as ‘inactive’ or ‘fairly inactive’ would be appropriate. ** Anyone falling into the high risk category using the Irwin & Morgan Risk Stratification Tool (see appendix 2) would be inappropriate for referral. Medico-legal considerations If referred by a health practitioner: • Clinical responsibility remains with the referrer. • Responsibility for safe and effective management, design and delivery of the exercise programme passes to the exercise professional.
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Operating Protocol for Referrers
1. Referrer identifies clients who are appropriate for referral
2. Client shows interest in participating and signs of readiness to change
3. Referrer completes referral form in FULL
4. Referral form is sent by post or fax to: Healthy Lifestyle Service The Bungalow 11 Park Road Keynsham BS31 1BX Fax:0117 9872292
5.Hub receive referral and send on to Project Officer – Health (where Physical Activity is ticked) for processing.
5. Project Officer - Health contacts patient to assess which activity pathway is most suitable based on their individual needs and arranges appropriate activity pathway.
6. Referrer receives a feedback letter if client completes the programme.
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Operating Protocol for Referral Exercise Professionals
1. Project Officer - Health (POH) receives referral form from hub and contacts client to assess their needs, assign activity pathway and advise on next steps. 2. Referral consultant receives paperwork and a call from the client and books an initial consultation.
3. Client attends an initial consultation to discuss health status (using PAR-Q), lifestyle issues and goals. An activity plan is established. Baseline measures are recorded and 6 and 12 week reviews are scheduled.
4. 6 week review is completed in order to monitor progress and make any necessary exercise programme/activity pathway amendments.
Motivational Lifestyle Programme All clients are invited to attend a weekly course aimed at helping clients to establish healthier habits related to their physical and mental wellbeing.
5. At 12 weeks, clients attend an exit assessment to discuss a new 12 week action plan and further goals are set. Baseline measures are repeated and clients are signposted to any relevant activity opportunities. A 3 month post-programme exit appointment is scheduled. 6. Client invited to 3 month post-programme exit appointment. Baseline measures may be repeated and an evaluation form is completed to establish activity levels. (Clients referred with depression have contact appointments at 14 weeks and 16 weeks before being discharged after 24 weeks)
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Activity Pathways Once an individual has been referred to the Passport to Health Service and has been contacted and needs assessed by the POH, one of the following activity pathways will be offered. OR
1 x 12 week Programme
Facility-based programme • Bath Sports & Leisure Centre • Keynsham Leisure Centre • South Wansdyke Sports Centre • Writhlington Sports
2 x 6 week Group Programmes
Group Cycling Course
Group Aquacise Course
Group Fitness Walking Course
Group Circuit Class Course
OR Community Activator programme • 1-2-1 exercise programme delivery for 12 weeks followed by 1 x 6 week course or alternative OR Give Us A Break Community Activator programme • 1-2-1 exercise programme delivery for unpaid Carers
All clients formulate an activity maintenance plan during their exit assessment.
Exercise for Depression – clients referred to manage their depression are prescribed enough exercise to benefit their mental well-being as recommended by the NICE guidelines. The pathways described above are offered based on assessment of their needs and preferences.
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Help Us to Help You
This document provides operational details about the Passport to Health Scheme. It is intended to help anyone involved with referring to the scheme understand the procedures involved when making a referral and using the service. If there is anything which could be made clearer or added to improve you understanding, please let the Project Officer - Health (POH) know by contacting: Project Officer – Health Sport & Active Lifestyles Team Bath & North East Somerset Council Lewis House (1st Floor) Manvers Street Bath BA1 1JG. Telephone: 01225 396427 Fax: 01225 396459 Email: P2H@bathnes.gov.uk
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Appendices • •
Hub referral form Irwin & Morgan Risk Stratification Tool
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Lifestyle Service Referral Form Service User Details (stick label)
Referral Date:
NHS Number: Mr Mrs Miss Ms Other Name: Address:
Postcode: DOB: Sex M / F
Home No: Mobile No: Work No: Email: Preferred contact? Home Mobile Work Email Consent to leave message Yes No GP Name / GP Surgery (stamp)
Pregnant Yes
Lifestyle Issues
Stop Smoking Healthy Eating Weight Management please complete GP consent section below for Slimming on Referral Physical Activity please complete GP consent section below for exercise referral
Patient Consent The reason for this referral has been explained to me. I want to participate and I give permission for this and any relevant information concerning my participation to be forwarded to the Lifestyle Service. Signed: Referrer Details Name:
Signature:
Place of Work:
*Position:
* If you are not a medical professional please ensure your service user consents to liaison between the Lifestyle Service and your service user’s GP (GP details in top section). Consent for liaison given (please tick)
If a GP/NURSE – please complete this section Weight (Kg)
Height (m)
GP / PRACTICE NURSE CONSENT SECTION BMI BP (must be <180/100mmHg)
GP Consent for Slimming on Referral (Midwife consent if patient is pregnant) I recommend that the above patient to participate in this programme. Their BMI is ≥28 with co-morbidities, or BMI ≥30 (>27 for BME patients). GP Consent for Passport to Health I am referring this individual for a prescribed programme of physical activity and can confirm that the service user is clinically stable and does not have any contraindications to exercise as indicated in the Guidelines for Referrers Reason for Exercise Referral CVD risk / mental well-being High Need Support Exercise for Depression Inactive (< 60 mins p/w) Inactive (< 30 mins p/w) Performing less than 45 minutes BMI > 30 (or >27 for BME patients) Financial barriers of physical activity 3 x p/w Family history of CHD Social barriers Diagnosed mild/mod depression BP or cholesterol Physical restrictions Post natal depression Type 2 diabetes Carer commitments Low mood / stress Current Medications: (print prescription) Other relevant medical history/exercise recommendations: (print patient summary and attach) Please return this form to the Lifestyle Service by Fax on 01225 831498 or 0117 9872292 Post to Health Improvement Services, The Bungalow, 11 Park Road, Keynsham, BS31 1BX or call 01225 831852 or 01225 831847 for more information or referral advice
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Irwin & Morgan Risk Stratification Tool The Irwin and Morgan Risk Stratification Tool takes the form of a simple traffic light system, the categories of risk are demonstrated below: LOW RISK Overweight High normal blood pressure Deconditioned Type 2 diabetes Older people aged >65
Antenatal Postnatal Osteoarthritis Mild bone density changes Exercise induced asthma Smoker
Stress/mild anxiety Seropositive HIV MEDIUM RISK Hypertension Stage 1 Type 2 diabetes Type 1 diabetes
Physical disabilities Moderate OA/RA Clinical diagnosis Osteoporosis
Surgery â&#x20AC;&#x201C; Pre and Post Intermittent claudication Stroke/TIA Asthma COPD Neurological Conditions
Early symptomatic HIV
No complications (130-139/85-89) not medication controlled Due to age or inactive lifestyle Diet controlled No more than 2 CHD risk factors and not at risk of falls No symptoms of pre-eclampsia / no history of miscarriage Provided 6/52 check complete and no complications Mild where physical activity will provide symptomatic relief BMD >1SD and <2.5 SD below young adult mean Without other symptoms One other CHD risk factor & no known impairment or respiratory function Asymptomatic
(140-159/90-99). Medication controlled Medication controlled With adequate instructions regarding modification of insulin dosage depending on timing of exercise and warning signs No other risk factors With intermittent mobility problems BMD -2.5 at spine, hip or forearm or _> 4 on Fracture index, with no history of previous low trauma fracture General or Orthopaedic. Not Cardiac. No symptoms of cardiac dysfunction >1 year ago. Stable CV symptoms. Mobile no assistance required Mild (ventilator limitation does not refrain submaximal exercise) Without ventilator limitation but would benefit from optimisation of respiratory system mechanics and correction of physical deconditioning E.G YOUNG ONSET Parkinsonâ&#x20AC;&#x2122;s Disease (stable); Multiple Sclerosis Moderately diminished CD4 cells, intermittent or persistent signs and 12
Chronic Fatigue Syndrome Depression Fibromyalgia
HIGH RISK Older people >65 years at risk of falls. Frail older people with osteoporosis and history of fracture
Unstable and uncontrolled cardiac disease Claudication with cardiac dysfunction Orthostatic hypotension Stroke/TIA Severe Osteoarthritis/Rheumatoid arthritis Type 1 or Type 2 Diabetes (Advanced) Moderate to severe arthritis COPD/emphysema AIDS
Psychiatric illness/cognitive impairment/dementia
symptoms e.g. fatigue, weight loss, fever, lymphadenopathy Significantly deconditioned due to longstanding symptoms Mild to moderate Associated impaired functional ability, poor physical fitness, social isolation, neuroendocrine and autonomic system regulation in disorders.
REFER DIRECT TO FALLS SERVICE (BMD) >-2.5 at spine, hip or forearm in the presence of one or more documented low trauma or fragility fractures). REFER DIRECT TO FALLS SERVICE
Fall SBP -20mg/Hg or DBP -10mg/Hg within 3 mins of standing Recent (>3 months ago) With associated mobility With associated mobility With accompanying autonomic neuropathy, advanced retinopathy With true ventilatory limitation With accompanying neuromuscular complications severe depletion of CD4 cells, malignancy or opportunistic infection AMT score <8
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