Referral Guidelines

VNH is Dartmouth Health’s preferred provider and most trusted choice for compassionate and collaborative hospice and home health care.

The VNH team partners with patients, families, and providers to provide the best quality care.

Epic Providers can refer patients for VNH services seamlessly within Epic.  Benefits include:

• Streamlined referral process
• Direct access to patient notes from the VNH staff caring for your patients
• Streamlined communication using the in-basket messaging system within Epic

Providers using other Electronic Medical Records can refer patients for VNH services by completing the Home Health & Hospice Referral Form and faxing it to 603-640-6851.

VNH also accepts referrals via Wellsky, CarePort and AIDA Healthcare.

Completed forms can be faxed to 603-640-6851. You can always give VNH a call to refer a patient at 800-575-5162.

For information around eligibility requirements, see below:

Face to Face Requirement for Home Health

Medicare requires documentation of a completed, valid, and signed Face to Face encounter in order for a patient to be eligible for home health services. The Face-to-Face encounter is a Medicare requirement; however, most insurances have followed Medicare and also require a valid Face to Face. The encounter must be completed by a PECOS enrolled physician, or other approved non-physician practitioner, which can include nurse practitioners, clinical nurse specialists, and physician assistants. The Face-to-Face encounter must be performed by the provider who will be following the patient during the home health episode, unless a patient is referred directly from an inpatient facility.

Required components of a Face-to-Face encounter document:

• A clinical note performed and signed and dated by an allowed provider type. A handwritten signature must have a handwritten date and an electronic signature and date must be clearly identified as being an electronic signature.  If the encounter is performed by a resident, the encounter note must be co-signed by the supervising attending who will follow the patient during the home health episode.
• Encounter may be up to 90 days prior to the home health start of care or may take place within 30 days after the start of care.
• The encounter must be related to the reason for the referral and admission to home health. The not must include the clinical diagnosis, assessment and plan for the treatment of the issue.
• The encounter or related documentation from the facility or provider must include documentation supporting that the patient is homebound.

Valid Face to Face encounter documentation can be found in an office visit note, progress note, emergency department notes and discharge summaries.  Please note that not all discharge summaries include a valid assessment/clinical findings. If it only includes patient instructions, medication list, nursing or therapy notes, it is not a valid Face to Face.

Please reach out to the Intake team at 800-300-8853, Option 1 with any questions related to the Face-to-Face documentation. We are here to assist you and help make the referral process go as smoothly as possible.

Valid Reimbursable Diagnoses

Medicare reimbursement is determined based on the patient’s diagnoses.  The primary diagnosis must be as specific as possible and there are a number of diagnoses that are excluded from payment.  Many of these excluded diagnoses are unspecified diagnoses or symptoms, such as weakness, debility, abnormal gait, dizziness, and fatigue.  They can also include diagnoses that do not specify whether the injury, surgery or wound is on the right or left side of the body.

The home health primary diagnosis should reflect the underlying cause for the patient symptoms and be as specific as possible. Some examples may include:

Muscle weakness, Generalized weakness: 

Consider: What is the reason the patient is presenting with muscle weakness? Did the patient have surgery, an injury, cardiac or respiratory condition? Did the patient have an infection? Identify what caused the weakness.

Debility

Same as weakness guidance. Old age is not a valid diagnosis under PDGM.

Abnormal gait

What is the abnormal gait related to? Is there an underlying neurological cause? Even variations of abnormal gait such as ataxic gait, difficulty in walking, etc. are not allowed as a primary diagnosis by Medicare.

Superficial injury codes

Superficial injury codes, most used to capture skin tears and abrasions, are NOT allowed as a valid primary diagnosis by Medicare. Consider a laceration code, if more appropriate. Why did the patient receive a skin tear? Falling? Loss of balance? Identify the cause rather than the symptoms.

Please reach out to the Intake team at 800-300-8853, Option 1 with any questions related to the appropriate diagnosis. We are here to assist you and help make the referral process go as smoothly as possible.

Guidelines for Hospice Referrals

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Valid Reimbursable Diagnoses

The decision to enter hospice is a difficult one for patients, their caregivers, and their providers. Patients receiving hospice services from VNH benefit from:

• Dedicated hospice RN who coordinates with the entire hospice team
• Emotional and spiritual support for patients and their caregivers
• 24/7 phone support for changes in clinical status and after-hours home visits for difficult situations
• Expert pain and symptom management guided by our hospice-certified medical director
• Shared medical record with DH primary care providers, specialists and VNH’s hospice care team

Providers utilizing hospice services from VNH benefit from:

• Clinical assessments and progress reports
• Decrease in patient/family crisis calls
• Support of hospice Medical Director
• Availability of office co-visit by hospice nurse to assist with patient education and end-of-life decision making
• Primary physician remains a member of the hospice team

Hospice can be appropriate for patients with either a cancer or non-cancer diagnosis. Admission to hospice requires a clinical judgment that a patient’s prognosis is less than six months should the disease follow its normal trajectory.  Non-cancer illnesses tend to be unpredictable and characterized by fluctuations in both symptoms and their severity, making hospice diagnosis more difficult. However, patients do benefit most from early referrals to a hospice program.

Please reach out to the Intake team at 800-300-8853, Option 1 with any questions related to hospice eligibility . We are here to assist you and help make the referral process go as smoothly as possible.

Patients with the following conditions may be appropriate for hospice: