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Referring to Home Care

Learn how to refer your patients to home care.

Home Care and Recovery

According to a 2015 study published in the American Journal of Managed Care, people who don’t receive home care after a hospital discharge are twice as likely to be rehospitalized as those who do get home care.

At VNS Health, we make it easy for you to refer patients and clients to home care — so they can get the care they need to heal and recover at home.

Home Care Eligibility Criteria

For eligible home care patients, VNS Health can provide skilled nursing, rehabilitation therapy, social work and behavioral health care, and guidance with advance care planning.

Our home care services support patients in all stages of recovery and treatment. Skilled nursing from the VNS Health Home Care team can:

  • Assess health status, and monitor and treat pain and symptoms
  • Coordinate care across disciplines and transitions of care 
  • Educate patient and family about self-care, disease treatment, and prevention 
  • Reconcile and monitor complex medication regimens 
  • Provide specialized care for patients with high risk of hospitalization, including care for postsurgical wounds and other complex treatment needs

Criteria for VNS Health Home Care

Your patient may be eligible for home care if they meet one or more of the following criteria:

  • Is recovering from acute illness
  • Has a disability
  • Is depressed
  • Is cognitively impaired
  • Requires post-operative care, such as wound or catheter care
  • Must follow complex medication plans
  • Has somewhat reduced abilities, but chooses to live independently at home
  • Needs assistance with activities of daily living with registered nurse supervision 
  • Requires physical therapy, occupational therapy, or speech-language therapy
  • Is homebound as defined by Medicare

Criteria for VNS Health Rehabilitation Therapy

PT = physical therapy
OT = occupation therapy
SLP = speech-language pathology

If your patient has difficulty with:They may be eligible for:
Ambulation (gait abnormality, new assistive device)PT
Going up or down stairsPT
Balance (fall risk or history of falls)PT
Bed mobility (scooting, turning, sitting up)PT/OT
Transfers (toilet, tub, sit to stand)PT/OT
Weakness or deconditioningPT/OT
Safety (concerns about living alone) PT/OT
Dyspnea/difficulty breathing at any levelPT/OT
Balance disordersPT/OT
Cardiopulmonary conditions (pre-/postsurgery, endurance issues, energy conservation, activity modification)PT/OT
Dressing/groomingOT
BathingOT
Feeding/meal preparationOT
Confusion at any level, including memory problemsSLP/OT
SwallowingSLP
Articulating clearlySLP

Medicare Definition of Homebound

If your patient is using Medicare or some commercial/managed care insurance plans, they must be homebound to receive home care services. 

Homebound is when a patient is unable to leave their home without considerable and taxing effort. They must also meet criterion 1 and criterion 2:

Criterion 1

They need the aid of one of these supportive devices or modes due to illness or injury: 

  • Crutches
  • Wheelchair
  • Walker
  • Special transportation
  • Help from another person to leave home, including for cognitive or psychiatric concerns

OR

They have a condition that makes leaving home medically not recommended.

Criterion 2

They have symptoms that make leaving home a significant effort. Examples include:

  • Shortness of breath
  • Pain
  • Anxiety
  • Confusion
  • Fatigue

Keep in mind — patients may still be considered homebound even if they can leave the home infrequently for short excursions or for health care needs. Some examples include: 

  • Religious services
  • Haircuts
  • Short walks, such as around the block
  • Family events, such as funerals or graduations, or other unique events
  • Outpatient kidney dialysis, chemotherapy, or radiation therapy

Refer a Patient to Home Care

Refer a Patient Online

Submit your home care referral online.

Refer a Patient by Phone

To refer a patient for home care by phone, call 1-866-632-2557.

Refer a Patient by Fax

Download the home care referral form and fax it to 1-212-290-3939.

Related Resources

Referring to Hospice Care

Referring to Behavioral Health

Need a home care referral form?

Or contact us through our online form, and we’ll get back to you (usually within 24 hours).

Refer patients to VNS Health.