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Home Care - Physician FAQ - New York City - Montefiore Medical Center
Who should I refer for home care services?
Any patient who is in need of skilled services such as nursing, physical therapy, occupational therapy or speech therapy can be referred for home care services. These needs may arise at the time of transition from the hospital or nursing home, during an exacerbation of a chronic condition or in association with a new diagnosis or illness.
- Poorly controlled chronic illness (heart failure, diabetes, HTN)
- Nurse for disease management including vital signs monitoring, medication education and adjustment, monitoring of compliance with diet and treatments.
- Administering and teaching Lovenox injections, monitoring blood pressure and education about other high-risk related complications.
- Frequent falls, gait instability
- Physical therapist for gait assessment and training.
- Occupational therapist for home safety assessment
- Orthopedic conditions (post-fracture repair, joint replacement)
- Physical and Occupational therapy for evaluation and management
- New ostomy or feeding tube
- Nurse for patient/caregiver instruction in dressing changes, ostomy care and administration of tube feedings.
- Neurologic impairment (stroke, MS, Parkinson's, TBI, SCI)
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- Physical and occupational therapy for evaluation and treatment
- Speech evaluation and therapy for swallowing difficulties, expressive and receptive language re-education, and cognitive training
What other services are available for patients who are receiving services at Montefiore Home Care?
Once a skilled service is in place, other services that can be provided in the home are:
- Social work services
- Occupational therapy
- Coordination of home health aide services
What makes Montefiore Home Care different from other home health agencies?
- CHF Program
- Management of Wounds
- Rehab program for Total Joint Replacement
- Covid Pulmonary Program
Who pays for Home Care Services?
- Medicare
- Medicaid
- CMO
- Private insurance
- Private pay
- Financial aid
How do I make a referral to Montefiore Home Care?
- Moses Liaisons: 718-920-7108
- Weiler/Einstein Liaisons: 718-904-2828
- Allscripts Care Management Portal (formerly ECIN) – refer to portal instructions to create referrals and upload required forms
- Outpatient referrals:
- Fax a community referral form to 718-367-0111
- Click here to download form.
- Call the central intake unit at 718-405-4800
- For patients who require a Face to Face Encounter Form, please click here to download the form here and fax to 718-367-0111
