Home Care Referral Indicators (Adult)

Home Care Services

Acute illness requiring initial assessment/teaching.

Assistive device teaching, CPM use reinforcement.

Chronic illness with an exacerbation, requiring follow-up assessment/teaching to prevent further hospitalization.

Diabetic teaching/monitoring including BG monitor, insulin administration.

Foley care/replacement-catherization teaching.

Heart failure telemedicine

Hospice evaluation

Infusion patient that requires teaching/assessment/monitoring when discharged to home (PICCs, Ports, Broviacs, Hickma).

Injectable medication administration/teaching (i.e. Fragmin).

Limited supports especially in elderly or frail patients.

Long-Term Home Health Care – program patients or prior to admission home care involvement.

Medication regime that is new or complex requiring follow-up teaching at home (including multiple oral meds, inhalers, nebulizers, anticoagulants).

Non-compliant patient who may need ongoing monitoring to prevent further crisis/hospitalization.

Nutrition therapies (tube feedings, TPN).

Oxygen, nebulizers, inhalers that are new, teaching or assessment needed.

Palliative care requiring symptom management (pain/nutritional/respiratory).

Rehab for change in functional status, transition to home, fall history, safety risk, or development of a maintenance program (OT, PT).

Speech Therapy for cognitive, speech or swallowing deficits.

Surgical procedures requiring assessment/monitoring/teaching.

Tube, drain or stoma requiring care and teaching.

Wound care/Dressing change requiring teaching or complex wound that require assessment for healing, consultation, VACs, ostomies.