Add Referral / Patient

ROLE PRIVILEGES NEEDED: <udl-white>Add Referral / Patient<udl-white> | <udl-white>Add Referral Source<udl-white>

SETUP: <udl-white>Referral Source Type<udl-white> | <udl-white>Physician Specialty<udl-white> | <udl-white>Physician Title<udl-white> | <udl-white>Facility Type<udl-white> | <udl-white>Referral Method Type<udl-white> | <udl-white>Payer Reporting Group<udl-white> | <udl-white>Facilities<udl-white> | <udl-white>Facility Type<udl-white> | <udl-white>Relationship Type<udl-white> | <udl-white>Referring DIagnosis Code Required<udl-white> | <udl-white>Skills<udl-white>


CREATING A REFERRAL <returntomenu>menu ↑<returntomenu>

To create a new referral go to Patients > Add Referral/Patient

Choose your "Agency" if you have more than one.

Then choose your "Agency Type".  

You can either click on the drop down and choose a recent referral source OR

Click on the <icon-magnify>xxx<icon-magnify> <udl-orange>Find Referral Source<udl-orange> Link to search for one. </udl-orange></udl-orange></icon-magnify></icon-magnify>

When searching for a referral source, you can search by:

  1. first or last name, or
  2. facility name.  To avoid issues of not finding the referral source because of spelling, I recommend not entering anything and just clicking on
  3. <btnw>   Search   <btnw>

The search dialog appears.  From here you can:

  1. Search again
  2. Select a referral source - You can click on the checkbox to the left of the referral source to choose them.  
  3. Save or Cancel
  4. Add Referral Source - In the event, you do not see your referral source, you can add them by clicking on the <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Referral Source<udl-orange>  link.

You have the following options available to choose from:

  1. Referral Type
  2. First Name
  3. Middle Initial
  4. Last Name
  5. Email
  6. Sales Rep
  7. Start Date
  8. End Date
  9. Physician Group
  10. Specialty
  11. Title
  12. Enter the required information and select <btnw>   Save   <btnw> when finished.

REFERRAL SOURCE  <returntomenu>menu ↑<returntomenu>

Referral History is a good way to see the past referral history for the Referral Source you have selected.  If you see that you are getting referrals from this referral source but there are not many admits, this may be a clue that you need to do some education with the referral source on Eligibility.

Select the drop down <btnw>   < select method >      ▾ <btnw>  to the right of Method of Delivery to make your choice.  You have the following choices available:

Select the drop down <btn>   All      ▾   <btn> to the right of Sales Rep and make your choice. The Sales Rep must be an associate of the agency in order to show in the list.

You can either choose the referral source from the drop-down of recently used referral source contacts, OR

add one by choosing the <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Referral Source Contact<udl-orange>  link.

Enter the required information and select the <btnw>    Save   <btnw>.

Select the drop down <btnw>   < select >       ▾ <btnw> to the right of  Payer Category and make your selection. You have the following options:

Enter the “Referral Date”.

The "Requested Start of Care" date populates the M0102 within the OASIS.  If the physician didn't specify an admit date, leave this blank.

Select the drop down <btn>   < select>     ▾   <btn> to the right of Admission Source to enter where the referral came from.

Select the drop down <btn>   < select>     ▾   <btn> to the right of Admission Type to choose the type of admission. You can have the admission type automatically populate with "Elective" if you activate the agency rule for Referring Admission Type – default to Elective

To match availability of associates and make sure that you can provide staff to take care of your patient, you can search the zip code of the patient for possible matches.  Enter a zip code and select <btn>    Show associates in zip code    <btn>.  

This will drill the list down to only the associates that are available in that area.  

You can either (1) decline the referral or (2) Continue Referral.  Select <btnw>  Save and Continue ▸   <btnw>

FACE TO FACE PHYSICIAN <returntomenu>menu ↑<returntomenu>

You can identify the Face-to-Face Physician and date as part of the process.   You can search your physician file by first or last name and select the physician that performed the Face-to-Face for the patient.  After you select your physician, a pop-up screen displays for Face-to-Face data collection.  When you create your 485, this information will display in the Face-to-Face section.

(1) Enter a last name or first name for the physician that completed the patient’s Face-to-Face visit (optional – you can still collect this information as part of the 485) and select the (2) Search button

Select a physician from the list that displays (Face-to-Face Visit pop-up displays)

The F2F popup displays. You have the following information to fill out:

  1. Enter the F2F visit date
  2. Enter the "Visit Comments"
  3. The Type...
  4. Attestation Statement...
  5. My Clinical Findings Support the need for the above services because...
  6. Certification for Medically necessary services...
  7. Homebound Status...
  8. Other Reasons For Homebound Status...
  9. Select <btnw>    Save   <btnw>

EDIT FACE TO FACE PHYSICIAN <returntomenu>menu ↑<returntomenu>

Face-to-Face Physician information displays; you can <udl-orange>[Edit]<udl-orange> OR...

DELETE FACE TO FACE PHYSICIAN <returntomenu>menu ↑<returntomenu>

<udl-orange>[Delete]<udl-orange> this information on this page.

NOTE:  If the 485 Face-to-Face visit date matches the Face-to-Face visit date you entered during the referral process, then the Face-to-Face information will not print/fax or email to the physician.

SEARCH FOR PATIENT <returntomenu>menu ↑<returntomenu>

Next you can "Search for Patient".  You can search by:

  1. first or last name
  2. date of birth
  3. medical record number
  4. patient identifier number.
  5. Enter the required information and select <btnw>   Search   <btnw>.  

This will allow you to do one of 2 things. Either you can select and readmit a discharged patient or create a new patient.

RE-ADMIT AN EXISTING PATIENT <returntomenu>menu ↑<returntomenu>

You can either "Re-admit an Existing Patient" by clicking on the check box to the left of the patients name and choose <btnw>   Continue ▸  <btnw> or "Add a New Patient".  You will notice here that several patient's had the name of "Smith", but only one is available to choose from.  You can not re-admit an active patient.  You only have the option to re-admit discharged patients.  

When you use the readmission process for a referral, you can pick which sections/areas of the previous admission that you would like to populate in the new admission.   Options available include:

Select the <btnw>   Continue   <btnw> button </btnw></btnw>(pop-up screen closes and moves to the Contact Info page).  Continue/complete the rest of the referral information, including Contact Info and Finish Referral pages.

ADD NEW PATIENT <returntomenu>menu ↑<returntomenu>

You can "Add a New Patient".  Enter the required information and select <btnw>   Continue ▸  <btnw>.

If you choose to re-admit a patient, you will be taken to the "Add or Edit Contact Info" screen.  You can edit this information by clicking on the <udl-orange>[Edit]<udl-orange> link either for:

  1. Address/Phone Info
  2. Ancillary Phone Info OR
  3. Patient Contact
  4. Select <btnw>   Continue ▸  <btnw> when ready.

ADD CONTACT INFO <returntomenu>menu ↑<returntomenu>

If you choose to "Add a New Patient", the "Add or Edit Contact Info dialog appears.  Select <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Contact Info<udl-orange> to enter address and phone information.

Here you can add the following information:

  1. Address Type & Address - If you choose "Currently Resides At", you will also be prompted with a start date and an end date (if applicable)
  2. Phone Type and Phone
  3. Preferred Phone - Be sure to select <btnw>    Add Phone   <btnw>, to update the preferred phone section to the right.  You can add multiple number is needed. Choose which number is considered preferred by clicking on the check box to the left of the phone number.  
  4. Enter required information and click "Save" when complete.  

When you enter Patient demographic information, suggested address or no valid address information displays. Options based on type of message displayed include <udl-red>Suggested address found<udl-red> - select the <btn>   Save   <btn> button to use the suggested address

Or select the <btn>   Continue   <btn> button to use the original information you entered  or you can make changes to the original information and select the <btn>   Continue   <btn> button

Or <udl-red>No valid address matches<udl-red> - select the <btn>   Continue   <btn> button to use the information you entered or enter new values and select the <btn>   Save   <btn> button


CURRENTLY RESIDES AT <returntomenu>menu ↑<returntomenu> 

When adding Patient address and phone information you have an Address type labeled "Currently Resides At" that you can select when a Patient is not currently living in their own home (i.e., temporarily staying with family, friends, etc.). This address type also lets you enter a "start" date as well as an "end" date so that you will know when to use this address information vs. using their home address information.

Select "Currently Resides At" from the "Address Type" dropdown list (pop-up redisplays with the Start/End date fields) and complete the information requested.

The <udl>Contacts<udl> tab redisplays with this information listed as "Currently Resides At Address"

ADD SERVICE FACILITY <returntomenu>menu ↑<returntomenu>

To add a Service Facility, select the <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Service Facility<udl-orange>  link.  

You can either search by name or click <btnw>   Search   <btnw> to see all.

From here you can:

  1. Search for a facility
  2. Select a facility
  3. Save your choice
  4. Add Facility Source - If you do not see the specific service facility. Once completed, this will bring you back to the "Add Contact Info" screen.  Select <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Service Facility<udl-orange> again and the facility you just added should be in the options to choose from when you search.

Choose the service facility that you want to add or add a new facility source and select <btnw>   Save   <btnw>.

Once you have selected the Service Facility, you will be prompted the enter the following:

  1. Address Type and Address
  2. Place of Service and start/end dates
  3. Phone Type and number
  4. Preferred Phone Number
  5. Select <btnw>    Save   <btnw> when completed

ADD PATIENT CONTACT <returntomenu>menu ↑<returntomenu>

To add a Patient Contact, select <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Patient Contact<udl-orange>.

Enter the required information and select <btnw>   Continue   <btnw> when finished.  Make sure to check "Family Portal", to give the Patient Contact Access to the Family Portal.  Email address is required for Family Portal access.  If the contact’s email address already exists in Careficient for a Patient, you will receive one of the following messages:

Enter the Patient Contact Information and select <btnw>    Save   <btnw> when finished. When you do not identify an option from the "Address Type" dropdown list, you only need to enter phone number information. If you select an address type, you will be required to enter an address.

ADD PHONE  <returntomenu>menu ↑<returntomenu>

To add an Ancillary Phone, select <icon-greenplussign>xxx<icon-greenplussign> <udl-orange>Add Phone<udl-orange>.

Here you can add the following:

  1. Phone Type
  2. Phone Number
  3. Extension
  4. Description
  5. Enter the required information and select <btnw>   Save   <btnw>when finished.

To continue filling out the referral, select <btn>   Continue    ▶︎   <btn> 

INITIAL PHYSICIAN ORDER <returntomenu>menu ↑<returntomenu>

The "Finish Referral" screen will display.  The physician should auto-populate from a previous screen.  Select the drop down <btnw>   < select >       ▾ <btnw> to the right of Physician Type and choose option.  

The "Requested Start of Care" date populates M0102 in the OASIS.  If the physician didn't specify a specific date, leave blank.

You have a checkbox that you can select if the Patient was transferred from another Agency. If you are not sure, you can leave the checkbox blank as you will be able to update this information within the Patient Encounter, <udl>Referral<udl> tab.

NOTE:  Agency Administrators, If you have the Org Payer Rule activated “Condition Code - Apply 47”, and you checked “Transferred from another Home Health Agency”, the invoice will require a condition code 47 on the UB04 invoice.  Or if you need to bypass the invoice edit you can add an invoice note “Turn off edit for condition code 47”.  

The remaining items are as follows:

  1. Physician orders are required.  Example:  SN to evaluate, formulate POC and begin treatment.
  2. Verbal / Written Order Date - You will be able to use the referral to document that you received the verbal order from the physician to initiate home health care. Select the "Verbal Order Date" <icon-calendar>xxx<icon-calendar>. This is the verbal order date when the clinician spoke to the physician.
  3. Apply My Signature - Select <icon-editpencil>xxx<icon-editpencil><udl-orange>Apply my signature<udl-orange> link to add your signature then select the <btnw>    Accept    <btnw> button. Remove My Signature - You can remove your signature by selecting the <icon-trashcan>xxx<icon-trashcan><udl-orange>remove my signature<udl-orange> link. You will not see your signature here, but it will be visible on the Referral Tab in the patient encounter.
  4. Surgical Procedure(s)
  5. Nutritional Requirements
  6. DME & Supply Information
  7. The "Referring Diagnosis Code" may or may not be required depending on your agency settings.
  8. Referring Diagnosis
  9. Medications

Under Disciplines and Specialty Skills you have:

  1. Disciplines should auto-populate from a previous screen.  
  2. If your patient requires certain skills and this is something you want to keep up with in reports, you can indicate what skills are required.  
  3. When you are finished, click "Continue".  This will take you to the Patient Encounters Screen.  Once the Referral is complete, this will generate the New Referral Work Basket Item.
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