Referrals and care coordination

Call our intake line at (818) 351-5250, and a member of our team will take the referral. Please do not send protected health information through this website or by ordinary email.

The most useful first call covers four things: the patient’s location, the working diagnosis and recent trajectory, the goals of care as documented or discussed, and who holds decision-making authority. Everything else can follow by records.

• Face sheet and insurance information, including Medicare or Medi-Cal numbers.
• Current medication list with doses and prescriber.
• Recent history and physical, discharge summary, or progress notes that document decline.
• Relevant diagnostics: imaging reports, labs, ejection fraction, pulmonary function, or cognitive assessment, as applicable.
• Advance directive, POLST, or healthcare power of attorney, if one exists.
• Attending physician name, contact, and whether they intend to remain involved.
• Primary caregiver name, phone number, and whether they are present during the day.

We do not require every item before starting an evaluation. Missing documentation slows the process; it does not stop a conversation.

We contact the patient or family to explain hospice and arrange an evaluation. The evaluation is a clinical assessment, not an automatic admission. If the patient does not meet criteria, or does not want hospice, we tell you and document the reasoning.

If the patient is admitted, we contact the attending physician for orders and certification. Where the patient is being discharged from a hospital or facility, we coordinate with the discharge planner on equipment, medications, and the first visit.

Timing depends on records, physician availability, and the patient’s condition. We will give you an honest estimate rather than a guaranteed number of hours.

Referrers receive confirmation of admission or non-admission, the plan of care summary, and notification of significant changes in condition, including hospitalizations, level-of-care changes, and death. Tell us how you prefer to receive updates and who should receive them.

If you are the attending physician and want to remain involved, we support that. If you prefer to transfer care to our medical director, we will confirm it in writing.

Hospice of Grace is based in Arcadia and serves all of Los Angeles County and surrounding areas. Whether we can accept a particular patient depends on the actual address and on the visit plan that patient needs, so it is best discussed with us directly.

Share the street and city, and our team can help confirm availability for your location and care needs. If a particular situation is beyond what we can serve well, we will say so and suggest what might help instead.

The intake line is answered 24 hours a day, 7 days a week, so a referral does not have to wait for business hours.

Some of the most appropriate referrals are the hardest to initiate: the patient with advanced dementia whose family has not accepted the prognosis, the heart failure patient on their fourth admission this year, the patient who says “I am not ready for hospice” while clearly deteriorating.

We are willing to have those conversations. A hospice evaluation can include an educational visit that ends without admission. Sometimes the most useful thing a referring clinician can do is introduce the option and let a third party explain it.