When a patient requires home health services after a hospital stay, our team oversees a coordinated, seamless transition with hospitals, inpatient care management teams and facility clinical staff of all medical facilities in the region. These transitions can occur between a patient's home and the following:

• Hospitals
• Acute Care Facilities
• Rehabilitation centers
• Skilled Nursing Facilities
• Assisted Living Facilities

We provide home health services for residents of assisted living facilities.

Most patients receive an initial home health visit by a nurse or therapist within 48 hours of discharge from the hospital.

Elligibility

The visit must have happened sometime in the 30 days before home health services are initiated or within 14 days after the home health nurse or therapist makes the first visit to the patient’s home

Once a patient has been identified as needing home health care, a clinician will visit the home/assisted living facility to do an initial assessment.

Initial assessment includes:

• Health status
• Living space
• Family/caregiver support
• Current medications

This initial assessment is very critical because we develop care plans for each patient based on their individual health care needs and the needs of their family or caretakers. Insurance requirements and financial expectations are also discussed during this visit. The responsible party must also be present for this initial visit.

Our staff understands that each physician or referral source operates differently, so we commit to providing patient feedback the way you want it. Each physician can designate how frequent they want to be updated and through which methods (fax, phone, email, etc.)

Physician Liaisons
MWHC Physician liaisons are also available to community physicians to bring us feedback about specific processes and procedures involved in home health care.

MWHC Physician Liaisons can be contacted at 540.741.1090 or physicianhelp@mwhc.com or our

Mary Washington Home Health Representative at 540.741.1667.

Referrals can be made by calling 540.741.1667 and speaking with Intake. There is a nurse on call evenings and weekends that can be reached through our answering service.

Medicare and Medicaid have established new requirements physicians must adhere to prior to their patients receiving home health services:

The referring physician (nurse practitioner, clinical nurse specialist, physician assistant) must have an "in-person" or face-to-face visit with all Medicare and Medicaid patients needing home health services.

• The visit must have happened sometime in the 30 days before home health services are initiated or within 14 days after the home health nurse or therapist makes the first visit to the patient’s home
• The reason for the in-person visit must match the reason or problem the patient is receiving home health services.

Click here for in-person or face-to-face visit requirement details

Call 540.741.1667 or email Homehealth.intake@mwhc.com to contact one of our intake specialists.