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Implementation

Tri-Borough Home Care accepts referrals from any source; hospitals, community organizations, nursing agencies, authorized practitioners, patients/families, third party payers, DSS, provided basic information about the patient and the need for service is available. The referring source is asked to provide:

  • Patient name and address
  • Insurance coverage or payer
  • Medical diagnosis
  • Type of level of service needed
  • Authorized practitioner’s name and address
  • Referrer name, title and phone number
  • Name and telephone number of primary caregiver and emergency contact
refer a friend

Tri-Borough Home Care accepts referrals seven (7) days a week. Referrals may be faxed twenty-four (24) hours a day. Faxed referrals will be acknowledged on the next business day.

Referrals will be reviewed for completeness; if necessary, the Home Care Coordinator or RN will contact the referrer or physician to obtain information. Referrals are accepted once all the required information is obtained.

Agency nursing staff will be assigned to conduct the in-house patient assessment within 24 hours of acceptance of the referral. The decision to accept the patient for care is made following the nursing assessment.

If agency services cannot be provided on a timely basis, or specific services are unavailable in the amount, frequency or duration required by the patient, the referring source will be advised no later than 24 hours after receipt of referral.

Policy: Admission

Purpose: To ensure that the agency admits only those patients whose health care needs can be safely met at home with the assistance of agency personnel and services. This determination will be made by a registered professional nurse following a patient assessment which will include consideration of the type and level of services required, adequacy of the home environment, participation of family or informal supports and availability of agency personnel.

Admission

A patient will be admitted for health care services after an assessment is made by a registered nurse, or an individual directly supervised by the RN to determine if the patient’s needs can be safely and adequately met by the agency.

Decisions regarding patient admission are made based on the patient’s health and safety, as well as the health and safety of agency staff. The agency is committed to providing ordered care and services while honoring the patient’s wishes to the extent practicable.
Patients are accepted for care without regard to race, color, religion, age, sex, national origin or handicap.

Criteria for Admission

The patient is under regular medical care, or is willing to seek medical care from a licensed authorized practitioner who will provide ongoing medical supervision and orders for treatment and services.

A patient diagnosed with active pulmonary tuberculosis will be evaluated for admission only if prior to patient’s assessment all of the following conditions are met:

  • The patient has been on an anti-tuberculin regime for at least two weeks;
  • The patient shows clinical improvement; and
  • Stained smears of three consecutive sputum samples are AFB negative.

As an outcome of the patient assessment, the nurse will identify and document:

  • the patient’s need for service and the type of care and service to be provided
  • the need for further assessment
  • available, willing and capable caregivers
  • educational needs of the patients, family or support system
  • possible victims of abuse
  • discharge planning and/or continuing care needs

Development of the Care Plan:

  • A written plan of care, based on a patient assessment by a registered nurse, is developed and implemented for each patient admitted for home care services. The nursing plan of care includes identification of problems, needs, goals, specific actions planned and the type and frequency of health care service to be provided.
  • The plan of care is made available to all staff involved in the care of the patient, including those providing contracted services, to facilitate appropriate coordination and continuity.
  • For patients requiring skilled care, the plan of care will include a problem list, which correlates with the physician’s orders, and is completed within five working days. Included with the problem list are goals and outcome criteria for each problem, specific interventions with frequency and duration.

Please use the form below to send us your referrals.