Home Health Referral in Wisconsin
SSM Health at Home provides a comprehensive variety of in-home services designed to assist you in helping your patients remain as independent as possible at home.
Resource Documents
The documents below contain information on processes and requirements for our most commonly requested home health services. If there is any information not posted here, that you feel would be helpful, we welcome your suggestions at hahwi.info@ssmhealth.com.
- Medicare Face-to-Face Requirements for Home Health
- How to Make a Home Health Referral
- Homebound Status for Home Health Services
- Patient-Driven Grouping Model (PDGM) Talking Points
- Physician Guide to Medicare Home Health Changes: The Patient Driven Groupings Model (PDGM)
- PDGM Physician's Toolkit Brochure
Homebound Status for Home Health Services
In order to receive home health services, you must be homebound, at least temporarily. Medicare considers you homebound if:
- Trips are short and infrequent
- You need help of another person to leave your home
- You need medical equipment to leave your home
- Your health care provider believes your condition could get worse if you leave your home
- If you are immunocompromised
- Going out is exhausting or challenging
- You CAN drive or own a car and still be homebound: drive to provider, church, beauty salon or anything to be considered therapeutic i.e. birthday party
Home Health Services Available
We offer a comprehensive variety of home health services – with one goal – to help our patients heal at home.
Development of individualized patient care plans and goals for patients to self-manage chronic conditions.
Assessment and education for patients with chronic diseases, such as, but not limited to:
- Heart failure
- Diabetes
- Hypertension
- Stroke
- Sepsis
- Cancer
- Pulmonary diseases (COPD, emphysema, asthma, chronic bronchitis, pneumonia)
Specialized program available to select health care facilities in which qualifying patients are provided an in-home visit from a nurse as well as four follow-up calls in order to reduce re-hospitalization. Qualifying patients receive:
- Medication review
- Education on health concerns and tools to self-manage condition
- Reminders about the importance of follow-up care
- In-home telehealth monitor
- Assistance in understanding the health care system and finding resources
Available to patients diagnosed with conditions including, but not limited to:
- Heart failure
- Stroke
- COPD
- Heart attack
- Pneumonia
- Those without a specific diagnosis but having:
- Problems regulating blood pressure
- Issues managing medications
- Chronic infections
- Difficulty following treatment plans
Provide short-term in tandem with skilled nursing/therapies to support the patient in achieving independence in the following areas:
- Bathing
- Dressing
- Exercises and walking
- Light housekeeping
- Meal preparation
- Medication reminders
- Medical device that collects patient vital sign and weights
- Information transmitted to SSM Health at Home professionals using a secure connection
- Results communicated to provider, as requested
- Early detection from using monitor will decrease the risk of hospitalization
- After home care, telehealth may continue at a private pay rate
- Evaluate needs and assistance in providing community resources
- Long-term care planning
- Assist patients with personal or family concerns that impact care and health
- Goals of care conversations
- Advance directives
- Providing education to patients/caregivers on:
- Medications
- Chronic disease management
- Home safety
- Symptom management
- Urinary catheter management
- Infection prevention
- Medication reconciliation and management
- Physical assessment, including vital signs and weights
- Home safety and fall risk assessment; refer to therapy if needed
- Symptom management
- Palliative care
- Diabetic management
- Wound care and treatments
- IV management and medication
- Lab draws
- Tube feedings
- Home telehealth monitoring
- Ostomy management
- Foley and suprapubic catheter management
- Collaboration with:
- Primary care physician and involved providers
- Care coordinators
- Assist in helping patients achieve wellness goals
- Lymphedema treatment
- Teaching patients to perform day-to-day activities, such as:
- Dressing
- Cooking
- Grooming
- Household tasks
- Bathing
- Assessment of need for, and assistance to obtain DME for patient to perform day-to-day tasks
- Assist with fine motor skills
- Upper extremity therapy - shoulders and hands
- Assist with sensory integration/processing helping to navigate a challenging environment with sensory limitations
- Assist with gross motor skills and musculoskeletal issues, such as walking, transfers, stairs, balance, posture
- Assessment and non-pharmacologic pain management
- Assess for safety in home and help patients find adaptive equipment for homes
- Patient education for adaption and use of new equipment
- Increase strength and endurance for those patients with a history of falls or hospitalizations
- Rehabilitation exercises to improve strength, motion and coordination
- Develop and educate on home exercise programs
- Assessment and education for patients with speech and swallowing disorder
- Communication challenges
- Difficulty swallowing or aspiration
- Support of stroke patients
- Support patients with Parkinson’s disease with swallow and voice challenges
- Assessment and training for patients with memory and cognition issues to work on strategies to improve memory and brain retraining