When to Refer to My Heart Care Services
A referral partner guide for identifying families and patients who may need home care, clinical support, or nurse-led care coordination.
Our team will review the referral and follow up promptly.
What This Referral Guide Covers
Five areas to help partners identify when a referral may be appropriate.
When a Referral May Be Appropriate
Common situations where a patient, client, or family may benefit from home care or clinical support — including discharge planning, unsafe home routines, chronic condition management, and caregiver overwhelm.
Types of Support Available
Home care, post-discharge support, clinical services, private duty nursing, and memory care.
How We Support Families
Care coordination, smoother transitions, and clear communication with partners.
What to Include in a Referral
Helpful information when submitting a referral: patient or family contact details, type of support needed, urgency or discharge timeline, and any relevant care notes. The form is brief — only what is needed to begin follow-up.
Referral Follow-Up Process
How the team reviews, responds, and keeps partners informed after a referral.
Who This Guide Is For
Built for the professionals and partners who support families every day.
Physicians & Clinical Teams
Identify patients who may need coordinated home care or clinical support.
Discharge Planners
Help patients transition safely from hospital or rehab to home with support.
Facilities
Skilled nursing and assisted living communities coordinating next-level care.
Social Workers
Case managers connecting families with appropriate in-home resources.
Community Partners
Organizations supporting older adults and families who may need care guidance.
Referral Situations This Page Can Address
Partners may need a simple resource to determine when My Heart Care Services is a good fit.
Patient being discharged from hospital or rehab and needs support transitioning home safely.
Family caregivers expressing stress, burnout, or inability to manage care needs alone.
Patient living alone with fall risks, missed medications, or difficulty managing daily tasks.
Ongoing health needs that require regular monitoring, medication management, or skilled care.
Dementia or Alzheimer's diagnosis where the family needs structured, supervised support at home.
Private duty nursing, IV therapy, wound care, or other clinical services required in the home.
Questions This Page Should Help Answer
When should a patient or client be referred?
A referral may be appropriate when a patient is being discharged and needs home support, when a family is overwhelmed by caregiving, when care needs exceed what family can manage, or when a patient's safety at home is a concern. If you are unsure, submitting a referral allows our team to assess the situation and advise on next steps.
What types of care needs can My Heart Care Services support?
We support a full range of needs including personal care and companion services, post-discharge recovery support, chronic condition management, clinical services (private duty nursing, IV therapy, wound care), memory care and dementia support, and care coordination. Our nurse-led team develops care plans tailored to each patient's situation.
How does the referral follow-up process work?
After a referral is submitted, our care team reviews the information and follows up promptly — typically within one business day. We contact the family to understand their needs, discuss care options, and coordinate next steps. Referral partners receive updates on the status of their referral to maintain clear communication throughout the process.
What information should be included in the referral form?
The form asks for essential information to begin follow-up: your name and organization, contact details for the patient or family, the type of support needed (home care, clinical, memory care, or not sure yet), and any urgency or discharge timeline. Additional notes are optional. If you are missing some details, you can still submit the referral and our team will gather the rest during follow-up.
Why My Heart Care Services
A strong partner for families who need coordinated, nurse-led care at home.
Nurse-Led Guidance
Care plans developed and overseen by licensed nurses with clinical expertise.
Full-Spectrum Services
From personal care to clinical services, private duty nursing, and memory care.
Partner Communication
Regular updates and coordination with physicians, facilities, and referral sources.
Timely Follow-Up
Prompt response to referrals so families get the support they need without delay.
Have a patient, client, or family who may need care?
Submit a referral and our team will follow up to discuss the care need and next steps.
Our team will review the referral and follow up promptly.
Submit a Referral or Request the Guide
Complete the form below and our care team will respond with the next steps.