How to refer a patient for in-home primary care.

What you are asking for

When you refer a patient for in-home primary care, you are asking for a primary care clinician to see someone where they live and take on the ongoing work an office would: chronic conditions, medications, new problems that are not emergencies, and planning ahead.

Gateway arranges in-home primary care through partner clinicians from treating practices that make house calls in Greater St. Louis and the Metro East. We coordinate the request, scheduling, records, orders and follow-up. The treating clinician makes every medical decision.

Patients this referral fits

The usual picture:

• No primary care visit in a long time because getting to the office is too hard
• Repeated emergency department visits for problems that built up over weeks
• A hospital or rehab discharge with a follow-up appointment the person cannot physically reach
• A medication list from several prescribers that nobody has reconciled
• A resident of assisted living or memory care whose doctor does not visit the community
• A wound patient whose diabetes, swelling or nutrition has no one managing it

Being homebound is not a requirement to ask. See primary care for homebound adults for how that term is used.

Five things to confirm before you send it

1. The patient agrees. We confirm with the patient or their representative before scheduling. A referral the patient has not heard about tends to end at the first phone call.
2. Whether there is a current primary care office. Home visits can work alongside an existing physician or replace that office. The choice belongs to the patient.
3. Where the patient will be living. Availability is confirmed by address and care setting, so the discharge destination matters more than the address on the face sheet.
4. The plan and the decision maker. Participation depends on the treating provider and the plan. Name the health care agent or guardian, if there is one.
5. How urgent it is. In-home primary care is planned care. A patient who is unstable needs urgent evaluation, and an emergency means 911.

What to send

Send what you have, even if it is incomplete:

• Name, date of birth, address, phone and entry notes for the home
• Payer and member number
• A recent history and physical or discharge summary
• The current medication list, with prescribers and pharmacy if known
• Recent labs and imaging
• Current primary care office and specialists
• Services in place: home health, hospice, therapy, equipment, aides
• A line on function and cognition: how the person gets around and who helps
• One sentence on what you want primary care to pick up

“Needs someone to manage heart failure medications after discharge” tells the clinician where to begin. “Needs a doctor” does not.

How to make the referral

Call 314-325-0126, fax 314-786-7966, or send a referral request. The web form collects contact details only, so keep clinical information to the phone or fax.

Gateway then contacts the patient or family, confirms availability for the location, goes over plan questions, gathers records with permission and schedules the visit. We do not promise timing, but we can tell you where the request stands. Hospital discharge planners can refer before the patient leaves.

How the setting changes the referral

Private homes. Tell us about stairs, pets, parking and who will open the door.

Assisted living and memory care. Tell the wellness director a referral is coming and ask how outside clinicians sign in and leave orders. See primary care in assisted living.

Skilled nursing and rehab. A resident in a skilled stay already has an attending physician. The referral that matters is usually for the day the resident goes home, as part of follow-up care after hospital discharge.

If the same person has a wound, say so in the same call. Gateway also arranges wound visits at home and facility wound rounds. See primary care and wound care together.

What to tell the patient, and how to close the loop

Patients and families should hear three things from you:

• Someone from Gateway will call, possibly from a number you do not recognize.
• For the first visit, have every medication bottle, insurance cards and discharge papers in one place.
• This is not for emergencies. Call 911 for chest pain, trouble breathing, signs of a stroke or sudden confusion.

On your side, record the referral date and put a follow-up task on your own list. If home health is in place, ask early which clinician will sign the agency’s orders going forward. The treating clinician and the agency settle that question, and they settle it sooner when the referral mentions it.

Common questions

Related pages

• In-home primary care
• Refer a patient
• Primary care for homebound adults
• Transitional care after discharge
• Medication review
• Hospitals and discharge planners
• Wound supply ordering for facilities
• Transport for outpatient wound visits