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Nexus Health PCHome Visits & Telehealth

FOR HOME HEALTH AGENCIES

Better coordination for patients who receive care at home.

Nexus Health PC works with home health agencies as a medical practice—not as a home health agency. Agencies may refer appropriate patients to Nexus, and Nexus may refer eligible patients back for skilled home-health services when clinically indicated.

Open Referral CenterCall (224) 666-0120

TWO-WAY CARE COORDINATION

How we can work together

1

Agency → Nexus referral

Refer a patient who may benefit from medical evaluation, pain-related assessment, medication review, mobility/fall evaluation, or other care within Nexus Health PC's scope.

2

Nexus evaluates

We evaluate the patient and determine medical needs individually. A referral request does not predetermine a diagnosis, medication, homebound status, or service order.

3

Nexus → Home health

When clinically indicated and applicable eligibility requirements are met, Nexus may order or refer for skilled nursing, physical therapy, and other appropriate covered home-health services.

4

Ongoing updates

The agency can send clinical updates through the secure workflow once activated, and Nexus can coordinate medical follow-up. The patient should be informed about recommended services and care coordination.

SERVICES PATIENTS MAY RECEIVE THROUGH A HOME HEALTH AGENCY

What PT and skilled nursing can look like at home

Physical Therapy

A home-health physical therapist may assess mobility, strength, balance, gait, transfers, fall risk, assistive-device use, and the home environment. The therapist develops measurable treatment goals consistent with the plan of care.

  • Gait and walker/cane training
  • Strength and balance work
  • Transfer and functional mobility training
  • Fall-risk reduction and home-safety education
  • Patient and caregiver instruction

Skilled Nursing

When ordered and medically necessary, home-health nursing may provide skilled assessment and monitoring, medication education/reconciliation, condition-specific teaching, and communication of meaningful changes to the medical team.

  • Clinical assessment and vital-sign monitoring
  • Medication education and reconciliation
  • Chronic-condition monitoring
  • Skin/wound assessment when part of the ordered plan
  • Care coordination and change-in-condition reporting

Nexus Health PC does not itself provide home-health agency PT or nursing through this website. The home health agency evaluates and furnishes its services under applicable orders, plan-of-care, coverage, and regulatory requirements.

HOMEBOUND & SKILLED-CARE DOCUMENTATION

Clinical criteria—not a diagnosis alone.

For Medicare home health, pain, a fall, or use of a walker does not automatically establish homebound status. The patient's overall condition must satisfy the applicable homebound criteria and the patient must have a qualifying skilled-care need. Nexus documents findings based on the actual evaluation and available records.

Supportive device or another person's help may be relevantLeaving home may be medically contraindicatedNormal inability to leave home must be consideredLeaving home must require considerable and taxing effortSkilled nursing/PT/SLP need or qualifying continuing OT need

Examples that may prompt evaluation

These are reasons to evaluate—not automatic qualification:

  • Pain limiting walking, transfers, or participation in therapy
  • Recent falls or worsening balance
  • Weakness or functional decline after illness/hospitalization
  • Need for walker, cane, wheelchair, special transportation, or another person's assistance
  • Neuropathic symptoms affecting mobility or safety
  • Medication or medical issues interfering with rehabilitation

REFERRALS & CLINICAL UPDATES

One place for partner communication.

Use the Referral Center to start a referral or prepare a clinical update. PHI/file transmission remains disabled in this website preview until Nexus activates a HIPAA-appropriate backend with required safeguards and agreements.

Referral & Communication CenterNon-PHI business question

Do not send patient information or attachments through ordinary email.