Step 1

Patient Qualifications

Can you or your loved one be a TRF Patient?

+ Do you live in Muntinlupa City?
We currently cater to residents in the City of Muntinlupa.

 + Do you have a chronic and debilitating illness?
This includes ALL forms of cancer, stroke, heart failure, ongoing dialysis, end-stage disorders of metabolism.

 + Are your Activities of Daily Living (ADLs) restricted?
Are you bedridden? Do you needs assistance when bathing, eating, and/or walking? Do you use any Medical Equipment like NGTs or other contraptions?

and/or

+ Are you Nonagenarian with complications?
This means that you are 90+ years of age and experiencing health problems.

 If your answer is YES to these following questions, you are qualified to be a TRF Patient.

Step 2

Call/ Walk-In

Give us a call at (632) 8 808 6079 or visit us at 2719 Entrata Tower 1 in Alabang and speak with our staff or nurses.

Be sure to provide the following information:

• A Valid ID (For those visiting our office, your ID will be collected at the ground floor lobby in exchange for a visitor’s pass)

• Birth Certificate

• Medical Certificate*

• Medical Abstract*

• Goals of Care*

• Recent PWD ID**

• Recent Laboratory Results**

• Discharge Summary**

*from your doctor
** upon availability

Our TRF Staff will orient you with the pre-requisites and conditions of the home visit.  You will then be scheduled for an initial home visit.

Step 3

Teleconsultation & Home Visit

The Nurse and Social Worker Initial Visit

They will familiarize you with the following:

• TRF’s Mission and Vision

• TRF’s Policies

• DSWD’s Requirements

• TRF’s Complementary Services

• Personalized Care Plan

• You will be signing consent forms and waivers, which will also be discussed during this visit.

Once completed, you will be scheduled for your first Doctor’s Home Visit.

The Doctor’s Visit

A doctor, nurse and social worker will visit you this time. Expect in-depth Palliative Care Management to be provided by the TRF team. You will then be scheduled for follow-up visits.

Succeeding home visits are based on your needs, as assessed by our team.

Services may include:

• Complementary Care Services

• Physical Therapy

• Social Services

Step 4a

DISCHARGE OF PATIENT

The following will be indicators for discharging patients from the TRF service:

+ Consent to receive service was retracted.
You may opt out of TRF Service at any time. This withdrawn consent should come from you or your immediate family.

 + Relocation to an out-of-area coverage.
Let’s say you decided to move to a location outside Muntinlupa City. TRF staff will prepare you and your family prior to transfer, and coordinate with other palliative care services for endorsement upon availability.

+ Recovery

• There are cases wherein patients are enrolled only because they are bedbound due to an acute illness. If the cause of illness was treated and the patient recovers, with an updated Palliative Performance Scale of 0, then the patient can be discharged.

•  If a patient with a chronic illness was treated from its acute illness, but the main chronic illness categorizes the patient to be under supportive status, he will not be discharged but only "RECATEGORIZED". Thus, no home visits will be done but expect that a phone follow-up will be done on a monthly basis.

•  Those patients who are confirmed to have non-malignant diagnoses and have high Karnofsky Scores (a performance status that quantifies a cancer patient’s well-being and ADLs.)

 + Death
Once a TRF Patient expires and after proper assessment of bereavement by the team, in coordination with our Social Worker, and the family was found to have no complicated bereavement, the patient’s family will be discharged from TRF’s Bereavement Care Service.

Step 4b

Bereavement Care

TRF’s Bereavement Care includes the funeral visit, follow-up Bereavement Care visits, counseling at our office and Baliktanaw.

In case of patient’s demise, please be guided accordingly:

+ Immediate family should inform TRF’s nursing team as soon as possible.

+ Prepare at least two (2) copies of the Death Certificate.

+ The Patient Care Coordinator (PCC) and/or the Nurse-in-Charge (NIC) informs our counselor and coordinates her funeral visit during the patient’s wake. The team visiting would include the NIC, our counselor, and/or the social worker.

+ Upon assessment, the counselor and PCC/NIC coordinates the follow-up care visit or counseling at the office with family.

+ After the demise of the patient, in a span of 1 year, TRF will be sending a Letter of Hope, done quarterly. This is to give hope and inspiration to the family during the expected grieving period.

Baliktanaw

This is a grief share activity of the foundation which aims to help the family of the patients of TRF recover from the hurt and grief after having lost their loved one due to illness.

+ Baliktanaw is done 2x a year.
Date may change according to availability of venue. They will be informed via text, call or email of the final date 1 month prior to event. Formal invitations will be sent 2 weeks prior to the event.

+ A maximum of 2 relatives per patient are invited to attend the session.
The closest family and primary care giver are the ones invited.

+ Family signs discharge form.
After the Baliktanaw session, if the TRF Counselor sees no pathologic bereavement, the case of the demised patient and his/her respective family will now be forwarded to the Social Worker for discharge.