Older Adult Care

No, patients do not need to be homebound to be seen by the Older Adult House Calls provider. The patient should, however, have a functional or cognitive limitation that makes traveling into the office difficult.

Older Adult House Call referrals are made through the patient’s primary provider office, York Hospital walk-in or York Hospital Emergency Department. The Older Adult House Calls provider will see the patient for a one-time visit. In some instances, there will be short-term follow-up for acute medical issues. Evaluation and treatment notes are completed in eCW and will be forwarded to the patient’s primary care provider. If requested or deemed necessary based on clinical impression, the House Calls provider may reach out to the provider office via phone call during or after a home visit to coordinate the patient’s plan of care. Ongoing follow-up should be provided by the patient’s primary care office, and the patient should continue to see their primary care provider for regular visits.

Referrals for a house call can be placed through eCW using the outgoing referral function. The referral should include the reason the visit is being requested, pertinent background information regarding the patient, goals of care if known, and any known safety concerns in the home.

Phone calls and telephone encounters to provide additional information are always welcome and can be helpful to start the process of setting up a house call. However, a referral into eCW is also required as this is used for tracking purposes and helps to ensure all referrals are addressed. If you are outside the York Hospital medical record, please fax appropriate referral documentation to our office at (207) 384-7929.

Once a referral is received, the patient will be contacted by the Older Adult House Calls provider within 1 business day, and a patient house call visit will typically be scheduled within 1-2 weeks. Time and date of the visit will be documented within the referral for reference and tracking purposes. Once the patient is seen, a note will be documented in eCW and then forwarded to the primary care provider. Any additional follow-up or care coordination required will be communicated with the primary care office.

Acute psychiatric episodes do not fall under the scope of the House Calls Program. Also, the need for a house call visit should not be based solely on the availability of transportation or weather-related challenges. Labs can be collected at visits as part of the patient’s care plan, so long as an assessment is also occurring and the visit is not exclusively for lab collection.

Vaccines could be given as part of a visit if the House Calls provider is already seeing the patient for another reason. The House Calls provider cannot make visits for the sole purpose of administering a vaccine.

Yes, the House Calls provider can see patients who are being followed by the VNA, as long as there is a specific need identified for advanced practice provider involvement in addition to the VNA.

On a case-by-case basis, it may be appropriate for the House Calls provider to make a visit to see a patient for a follow-up visit following a discharge from the hospital. The case manager at the primary practice or primary care provider can reach out to the House Calls nurse practitioner to discuss these types of visits. Inpatient providers are welcome to send appropriate referrals to our office at (207) 382-7292.

The Older Adult House Calls line phone number is answered by the Older Adult Service triage nurse. If the patient has an open referral to the House Calls program, the Older Adult triage nurse will assist the patient in scheduling a home visit appointment. If there is no open referral, the patient will be directed to their primary care office to discuss their symptoms and determine if a house call is appropriate to meet their needs.