For referring clinicians
Refer a patient for care at home
We see seriously ill and homebound adults in their homes across Philadelphia, Bucks and Montgomery County, for palliative care and for ongoing medical care with monthly care management between visits. Physicians, case managers, discharge planners, home health agencies and facilities can refer directly.
Good candidates
- Homebound or hard-to-transport adults with serious illness
- Frequent hospitalizations or ER visits
- Uncontrolled symptoms
- Recent hospital discharge needing close follow-up
- Multiple chronic conditions needing ongoing management at home
- Goals-of-care or advance care planning needs
- Patients not yet ready for or eligible for hospice
How to refer
Fax (267) 578-5338 or call (267) 412-3165. Please include:
- Face sheet / demographics
- Insurance information
- Recent clinical notes or discharge summary
- Medication list
- Reason for referral
What happens next
We contact the patient or family to schedule, see the patient at home, and send our assessment and recommendations back to the referring clinician.
Patients who qualify can be enrolled in chronic care management, so our team follows up monthly between visits to help prevent readmissions.
Who refers to us
- Hospitals and discharge planners
- Home health agencies
- Specialists: cardiology, pulmonology, nephrology, oncology, neurology
- Senior living communities
- Hospices