Referral process

To refer a patient to Housecall Providers Advanced Illness Care, first please review the screening tool below to ensure the patient is eligible for our program. If eligible, complete and fax the fillable PDF form below along with the requested record to 503-416-1323.

Metro Referral Form JCC Referral Form CPCCO Referral Form

Advanced illness care eligibility screening tool

Section 1

Patient has at least one of the following:

Cardiac disease
Liver disease
Renal disease
Respiratory disease
Neurodegenerative disease
Cancer
Cerebral vascular accident (CVA)/Stroke or dementia
HIV/AIDS
Frailty – Decrease in weight and/or function with two falls and/or infections in last six months
Multiple chronic conditions/comorbidities with at least two ED visits or one hospitalization in the last six months related to symptom management, chronic disease management, or acute event contributing to more rapid decline in health (PPS up to 50%).

Section 2

The patient meets at least one of the four criteria:

Two or more ER visit in the last six months
One or more hospitalization in the last six months
Hospital readmission in last six months
Current admission prompted by:
- Uncontrolled symptoms related to underlying disease (e.g. pain, shortness of breath, vomiting, confusion) and/or
- Inadequate home, social, family support

Section 3

The patient meets at least two of the six criteria:

Wouldn’t be surprised if this patient died within one year?
Decline in function, feeding intolerance, frequent falls, weight loss
Complex care needs: dependent on one or more ADLs, complex home support for care (oxygen, medications, insulin)
High risk factors/gaps in care: low health literacy, medication non-adherence, frequent no show to appointments, cognitive impairment, houselessness, homebound.
Pt declined hospice enrollment.
Complex goals of care: conflict amongst patient/family regarding GOC, patient refusing to engage in GOC/ACP activities

Section 4

The patient meets all listed criteria:

The primary diagnosis explaining the above is not psychiatric in nature.
The primary diagnosis explaining the above is not related to active substance use disorder (SUD). Will consider pts who meet palliative care with active SUD (use grey zone tool).
This referral is not related to primary pain management.
The patient is not currently enrolled in hospice.