When to Refer
Palliative care is most effective when introduced early in the disease process — alongside active treatment.
Refer patients who have advanced or complex illness and would benefit from additional support managing symptoms, medications, and care coordination.
Common Referral Triggers by Condition:
- Cardiology: NYHA class III–IV heart failure, frequent CHF exacerbations, EF < 30%, recurrent hospitalizations
- Pulmonology: COPD with frequent steroid or antibiotic use, home O₂, multiple ED visits for SOB
- Nephrology: CKD stage IV–V, on or declining dialysis, poor appetite, progressive weakness
- Oncology: Metastatic disease, declining functional status, treatment intolerance, high symptom burden
- Neurology: Dementia, Parkinson’s, ALS, CVA with residual deficits, progressive weakness or weight loss
- General Indicators: Uncontrolled pain, fatigue, poor appetite, weight loss, caregiver distress, frequent ED use or hospital readmissions
Co-Management Workflow
Palliative care works alongside primary and specialty teams, not in place of them.
Our approach emphasizes collaboration and communication.
- Referral Received → Triage within 24–48 hrs
- Initial Visit (NP) → Full symptom and goals assessment
- Plan of Care Shared → With referring provider via EMR or fax
- Ongoing Visits → Typically every 2–4 weeks for symptom management and psychosocial support
- Updates Provided → Summary notes, medication changes, and care coordination updates shared regularly
Focus on Reducing Medication & ED Utilization
Our data-driven model emphasizes:
- Deprescribing: Regular medication reconciliation to reduce polypharmacy and drug interactions
- ED Avoidance: access to support line for urgent symptom management to prevent avoidable ER visits
- Advanced Care Planning: Ensuring patient goals align with current treatments
- Continuum of Care Coordination: Seamless transitions between home, clinic, and hospital
Documentation Examples
We use standardized templates that streamline communication and compliance:
- Initial Visit Note: Symptom burden, goals of care, and medication review
- Follow-Up Note: Symptom score trend, interventions, and next steps
- Provider Update: Concise summary faxed/emailed to referring physician
Referral Service Level Agreements
- Referral Acknowledgment: Within 24 hours
- Initial Visit Completion: Within 7 business days (sooner for urgent cases)
- Provider Summary Sent: Within 48 hours of visit completion
- Ongoing Updates: Every 30 days or upon significant clinical change
Refer a Patient
Call: (210) 901-6000
Fax Referral Form: (210) 569-7779
Submit Referral Online