Homecare Referral Indicators (Adult)
 

• 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 (ie. 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.