SSM Health at Home & Hospice Referrals

SSM Health at Home provides a variety of services to meet your home health care and hospice needs. We want to do everything we can to help your patients receive the very best quality of care, as well as make the referral process as easy for you as possible. 

Make a home health referral.
Make a hospice referral.
Medical equipment referral forms.

If there is any information not posted here, that you feel would be helpful, we welcome your suggestions at hahwi.info@ssmhealth.com.

Refer a Patient to SSM Health Health at Home

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.

Helpful documents for making a home health referral:

For information about home health programs or to make a referral during business hours call:

Home health services available from SSM Health at Home:

We offer a variety of home health services – with one goal – to help our patients heal at home. Please note all services may not be available in all regions. 

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
  • 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

Have questions about the referral process for home health services?

Call 800-924-2273 to speak with someone or email our team at hahwi.info@ssmhealth.com.

Refer a Patient to SSM Health Hospice

SSM Health has two ways to refer patients:

  1. Providers in all regions can call 800-924-2273 to speak with an RN to take your referral.
  2. Use the current REF 35 process within Epic.

Want to speak to someone locally when referring your patient to hospice?

St. Louis West: 636-695-2050Greater Fond du Lac Area: 920-923-7950
St. Louis: 314-989-2800
Greater Madison Area: 608-242-1516
Southern Illinois: 618-899-1631
Oklahoma: 405-231-3755

Helpful documents for making a hospice referral:

Helpful documents for making a hospice referral:

Patient benefits of our hospice program:

  1. Rapid response: A hospice representative will contact your patient or their family within 60 minutes of your referral.
  2. Supportive decision making: If patient/family or physician prefers, SSM Health at Home can provide consultation visits before enrollment, helping patients and families clarify their goals and make informed choices.
  3. Proactive medication planning: SSM Health at Home uses standardized protocols to recommend medications in advance, so patients have what they need — when they need it.
  4. Primary physician still involved: The hospice team will regularly communicate with patient’s primary physician to ensure physician continues to direct patient’s care plan.
  5. Personal navigator: Hospice will guide patient and family on a personal level through the complexities associated with end of life such as medication administration, education, expectations, spiritual needs, emotional support for patients and families, and more.

Why SSM Health is the right choice for your patient:

Hospice care is meant to support people with serious illnesses during the last six months of life. Early hospice care helps families plan ahead to meet a loved one’s wishes with dignity and compassion. The earlier someone begins hospice, the sooner our care team can help manage pain, ease symptoms, and provide comfort. The earlier a patient enters hospice care can lead to a better quality of life. It can provide more time to fulfill wishes, more comfort and dignity, more support for families, and, in many cases, longer life.

We have a robust team of board-certified hospice and palliative care physicians available to:

  • Serve as a clinical resource for attending physicians.
  • Assume primary management of hospice care if the referring physician prefers to transfer care to the attending hospice physician.

Our EVIE (Every Visit Is Exceptional) program ensures consistent, high-quality care:

  • Standardized visit planning to ensure patients have all necessary support before the nurse leaves.
  • Structured communication protocols to enhance coordination.
  • Care plans are customized to each patient and care setting, while maintaining reliability across visits.
  • CMS Quality Rating: 87.6% (vs. 84% average among competitors, May 2024).
  • Likelihood to recommend: 87% of families would recommend our hospice care to their friends and family.
  • Symptom management: 82.1% (vs. 75% competitor average) patient and caregiver satisfaction reflecting a high level of contentment with pain management and symptom control.
  • Communication with hospice team: 85.1% (vs. 81% competitor average) indicating patient and caregiver satisfaction with hospice communication.
  • Our clinical quality scores consistently exceed national benchmarks.
  • 24/7 nurse triage center ensures timely response to patient needs.
  • Streamlined referral process:
    • Accepting referrals via phone or Epic.
    • Referrals submitted through Epic are acknowledged via in-basket message.
  • Biweekly care plan summaries delivered through Epic.
  • Ongoing updates to support continuity and transparency in care.

Have questions about the referral process for hospice care?

Call 800-924-2273 to speak with someone or email our team at hahwi.info@ssmhealth.com.

Home Medical Equipment Referral in Wisconsin

SSM Health at Home in Wisconsin provides a comprehensive variety of services and an extensive selection of equipment designed to assist you in helping your patients remain as independent as possible at home.

Helpful documents for commonly requested medical equipment: