Referring Patients During the COVID-19 Pandemic

VNH is fully operational and actively accepting referrals for all home health and hospice needs.

When referring patients during the COVID-19 pandemic, please include the following information along with the normally required referral information:

  • For patients who have exhibited respiratory or other COVID related symptoms: Date and location of COVID19 test and results if available.
  • If there are orders for aerosolizing treatments, it should be in the orders, med list or discharge summary.

For more detailed information on the CDC’s interim guidance for patients discharging to homecare:

CDC’s Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for COVID-19

Other COVID-19 related resources pertaining to home health:

State of Vermont FAQs on Maternal Child Health Services During COVID-19

VNH services are available 24 hours a day, 7 days a week.  Our team partners with patients, families, and providers to provide the best quality care. To refer a patient for VNH home health or hospice services, please complete the referral form below:

Home Health & Hospice Referral Form

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:

Guidelines for Home Care Referrals
Guidelines for Hospice Referrals

Patient Driven Groupings Model (PDGM), began January 1, 2020 and is a new home health reimbursement model under Medicare – the first major overhaul of the home health payment system since 2000. This will require greater collaboration.

Guidelines for Home Care Referrals

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The Medicare Home Care criteria can be confusing. VNH can assess the patient by phone or by making a nursing visit.

Definition of Homebound

The following examples can help determine if a patient is considered homebound

  • Most post-op patients can be considered “homebound” due to driving restrictions.
  • Absences are infrequent, of short duration and must contribute to the patient’s state of wellbeing: medical appointment, special occasion, hair appointment, church, a short walk.
  • Leaving home must take a considerable and “taxing” effort, with documented use of a supportive device, i.e. walker, cane, w/c, O2.
  • Patient requires assistance in order to leave the house – vision impairment, for example.
  • Person has dementia and cannot be left alone for safety reasons.
  • Patient has significant cardiac disease, causing fatigue.
  • Patient may attend a certified, licensed or accredited day care program.
  • Patient may drive, if the driving is done with “considerable and taxing effort.”
  • Homecare visits may be made on the same day the patient visits the MD, provided that the homecare visit and the MD visit are for different issues. (Ex. – VNA provides visit for wound care; MD appointment is for endocrine workup.)

List of Visiting Nurse & Hospice Services

  • Hospice
  • Skilled nursing and case management
  • Physical and Occupational therapy
  • Speech therapy
  • Palliative care
  • Wound care
  • Infusion therapy
  • Oncology services
  • In-home anticoagulation management
  • Telemedicine
  • Personal care

Clinical Specialties

For Adults and Children

  • Post operative care for all types of surgery
  • Rehabilitation from accident/illness
  • Recovery from exacerbations of chronic diseases
  • Rehab from physical impairment and adjustment to mobility changes
  • Fall prevention and pre-surgical home assessments
  • Medication management/education
  • Patient education
  • Assessment to determine need for home care services

Maternal and Child Health

  • High risk pediatrics
  • Pre-natal support for high risk mothers
  • Post-partum assessment/care for mothers
  • Post operative care
  • Rehabilitation from accident/illness
  • Oncology services

Long Term Care

  • Case management VT Medicaid waiver patients
  • Direct care/homemaking services for VT/NH waiver patients
  • Collaboration with NH HCBC case managers
  • Continuity of care between long term care and skilled services

Guidelines for Hospice Referrals

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Patients with Non-Cancer Diagnosis

Admission to hospice requires a clinical judgment that a patient’s prognosis is less than six months. 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 referral to a hospice program. Patients meeting two or more factors in any of the following categories are hospice appropriate:

General Guidelines

  • Life limiting condition
  • Progression of disease
  • Frequent hospitalization, office, ER visits
  • Weight loss > 10% over past six months
  • Serum albumin < 2.5dl
  • Patient/family focus on symptom relief, not cure

Benefits of Hospice program to providers:

  • 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 MD remains member of hospice team

End-Stage Pulmonary Disease

  • Dyspnea at rest
  • FEV 1 < 30% after bronchodilators
  • Recurrent pulmonary infections
  • Cor pulmonale / right heart failure
  • p02 < 55 mm Hg or 02 sat < 88% (on 0 2)
  • Persistent resting tachycardia
  • Cardiogenic embolic disease (e.g. CVA)
  • Weight loss > 10% over past six months

End-Stage Renal Disease

  • Patient not seeking dialysis or transplant
  • Creatinine Clearance < 10 cc/min «1 5cc/min for diabetics)
  • Creatinine > 8 mg/dl (>6 mg/dl for diabetics)
  • Symptoms of uremia (confusion, Nausea/vomiting, pericarditis), restlessness
  • Hyperkalemia > 7.0 mEq/L
  • Oliguria < 400 cc/24 hrs.

End-Stage Cardiac Disease

  • Symptomatic despite optimal treatment with diuretics and vasodilators
  • Recurrent CHF, NYHA Class III or IV
  • Ejection fraction < 20%
  • Arrhythmias are resistant to treatment
  • History of cardiac arrest or resuscitation
  • Cardiogenic embolic disease (e.g . CVA)
  • Angina at rest
  • Persistent resting tachycardia

End-Stage Liver Disease

  • Patient is not a candidate for a liver transplant
  • PTT > 5 seconds over control
  • Serum Albumin < 2.5 gm/dl
  • Ascites refractory to treatment
  • Peritonitis
  • Hepatic encephalopathy, refractory to treatment
  • Hepatorenal syndrome
  • Progressive malnutrition
  • Continued active alcoholism

End-Stage Dementia

  • Functional Assessment score > 7
  • Unable to ambulate without assistance
  • Unable to dress or bathe without assistance
  • Urinary and fecal incontinence, intermittent or constant
  • No meaningful verbal communication
  • Complications such as aspiration pneumonia, UTI, septicemia, recurrent fevers
  • Decubitus ulcers stage 3 or 4
  • Weight loss of 10% over last six months

Stroke and Coma

  • Coma or persistent vegetative state >3 days
  • Dysphagia: without artificial nutrition/hydration
  • Dependence in all ADLs
  • Post stroke dementia
  • Urinary and fecal incontinence
  • Family wants palliative care
  • Absent verbal response

ALS (End-Stage Neurological Diseases)

  • Wheelchair bound or bed bound
  • Barely intelligible speech
  • Difficulty swallowing
  • Nutritional status declining
  • Needs major assist in all ADLs
  • Dyspnea at rest: requires 02
  • Declines assisted ventilation

Patients with Cancer Diagnosis

  • Disease with metastases at presentation or progression from an earlier stage of disease to metastatic disease with EITHER continued decline in spite of further disease related therapy OR patient declines further disease related therapy.
  • Certain cancers with poor prognosis–small cell lung cancer, brain cancer and pancreatic cancer–may be hospice eligible without fulfilling the other criteria in this section.