Referral Care Checklist - Pathways Care

Determining the appropriate care for your patient or loved one can be a difficult task.

To help, use our Care Checklist or Referral Form and we will contact you to assist with the best level of care for your loved one.

Use our Referral Care Checklist Tool

The Care Checklist below will help you recognize and determine the level of care your loved one or patient requires. It is intended as a guide only. If you have any questions or wish to discuss the details of your loved one’s condition, please contact our admissions team and we will complete an assessment visit and admit your patient to the program that best fits their needs.

Are you ready to submit a referral?

If you are ready to submit a referral, please fill out our Online Referral Form.

Submit Online Referral

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Care Checklist Tool

Please review the following list of conditions and check each one that applies.

If you check four or greater boxes, your loved one/patient may qualify for our Palliative Care at Home program. If you check seven or greater boxes, your loved one/patient may qualify for Hospice. If you check between four and seven boxes, your loved one/patient could qualify for either our Palliative Care at Home or Hospice services. Once you have completed the Care Checklist, please provide your contact information and we will reach out to you to discuss how we can best meet the needs of our loved one/patient.

Patient Conditions

Has your patient been hospitalized two or more times in the last six months related to the same diagnosis?

Has your patient had a recent hospital stay that was longer than five days or required admission to the Intensive Care Unit?

Has your patient had two or more serious infections in the last six months?

Has your patient had two or more recent falls that caused a fracture or serious injury?

Has your patient had greater than 10 percent weight loss over the last six months or a current Albumin level less than 2.5?

Is your patient receiving maximum treatment with now worsening symptoms?

Is your patient refusing or no longer a candidate for aggressive treatments?

Does your patient have increased needs for community resources related to their disease or recent functional decline?

Does your patient need help with end of life advance care planning or a detailed goals of care conversation?

Do you suspect this patient’s life expectancy to be less than two years within the normal course of their disease?

Total Number of Selected Conditions:

Done with Selections - Review Results Below

Based on the conditions you selected, your loved one/patient does not officially qualify for either our Palliative Care at Home program or Hospice Service. If you would like to have an admissions coordinator call you to discuss your options, please fill out the information below.

Note: If you are ready to submit a referral, please fill out our Online Referral Form.

Based on the conditions you selected, your loved one/patient qualifies for our Palliative Care at Home program. Please fill out the form below to have an admissions coordinator call you to discuss your options.

Note: If you are ready to submit a referral, please fill out our Online Referral Form.

Based on the conditions you selected, your loved one/patient could be a candidate for either our Palliative Care at Home Program or Hospice. Please fill out the form below to have an admissions coordinator call you to discuss your options.

Note: If you are ready to submit a referral, please fill out our Online Referral Form.

Based on the conditions you selected, your loved one/patient qualifies for Hospice. Please fill out the form below to have an admissions coordinator call you to discuss your options.

Note: If you are ready to submit a referral, please fill out our Online Referral Form.

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