How Do I Make A Referral?
• PacificSource supplies a list of your patients who are current members of Medicaid, Medicare, or commercial PacificSource who meet qualifying criteria of eligibility
• The list will include information such as:
Medical claims total
Prescription claims total
Number of hospital or ED admissions
Number of qualifying diseases
Risk score for future claims
• From the list you have the liberty of choosing whichever patients you feel would benefit most from Bridges Health services. There is the added flexibility of PCP inclusion of patients not on the list.
• Bridges Health Medical Director will collaborate with you on selected patients to ensure that they are appropriate Bridges Health candidates.
• Bridges Health staff will supply you with the necessary tools to reach out to the patient and explain and “sell” the services or help with a warm-hand off.
• Once a patient has agreed, you will send a referral to Bridges Health including appropriate records.
• Once the referral is received by Bridges Health staff we will reach out to the patient to schedule a home visit and intake at the clinic.
• Prior to the home visit Bridges Health staff will review patient chart notes and create a profile in our EMR.
• Community Health Workers will complete a home visit or have the patient come into the clinic to obtain intake paperwork and initial screening tools.
• Patient is seen at Bridges Health Clinic for a comprehensive medical assessment..
• At this point the decision will be made if patient is a good candidate. If so, the patient enrolls and PCP change will be initiated with PacificSource.
- The referring PCP receives a copy of the intake visit and regular notes thereafter (quarterly)
• All subsequent follow up appointments will be done at Bridges Health, including tending to any acute needs or annual appointments.
• Upon graduation from Bridges Health the patient will be returned to referring PCP for all ongoing care.