For professionals
Clinical and social referral
A direct route for doctors, nurses and hospital social workers to refer patients who need continued care at home, in the Oeste region and around Leiria.
Referral confirmed within 24 business hours.
Who this is for
We accept referrals from anyone supporting the patient before discharge or in outpatient care.
- General practitioners and hospital doctors
- Community liaison nurses and discharge managers
- Hospital and municipal social workers
- Palliative care and public health teams
When to refer
If the patient meets at least one of these criteria and lives in a municipality we cover, it is worth talking to us.
- 1
Hospital discharge with health needs at home
A patient who cannot travel to a health centre in the first days after discharge and needs clinical monitoring, wound care, injectable medication or device management.
- 2
Chronic illness with poor access to primary care
Reduced mobility, dependency or geographical isolation, where a home consultation avoids painful journeys and repeated missed appointments.
- 3
Avoidable risk of readmission
Frail patients with recent emergency episodes who benefit from close monitoring and from someone who spots signs of deterioration.
- 4
Rehabilitation after stroke, fracture or surgery
Need for physiotherapy and functional training at home, with clear goals and liaison with the hospital team.
- 5
Chronic wounds and technical care
Pressure ulcers, surgical wounds, stomas, catheters and other nursing care that requires continuity and record keeping.
- 6
Carer strain and need for social assessment
Families needing home support, assistive equipment or social responses, who benefit from an assessment by a social worker.
- 7
Language barrier or family abroad
Foreign patients or patients whose children emigrated, who need support in English, French or Dutch and regular written reports.
When this is not the right service
In an emergency
This website and this email address are not for urgent situations. In an emergency call 112. For health advice call SNS 24 (808 24 24 24).
112- Urgent or emergency situations, which must go to 112 or the hospital emergency department.
- Patients needing admission, hospital diagnostic equipment or intensive care.
- Clinical procedures reserved for hospital settings, such as surgery, imaging or hospital sample collection.
- Immediate danger to the patient or to others, which requires the police, child protection services or a social emergency team.
What we need from you
The more complete the first message, the faster our answer. Send only the essentials by email; the remaining clinical data is collected by us, with the patient's consent.
- Patient's name, age and municipality of residence
- Contact of the patient or main carer, with permission to contact
- Reason for referral and main diagnosis
- Expected discharge date, if applicable
- Current medication, devices and technical care in place
- Referring professional and service of origin
- Social needs already identified, if any
How it works
- 01
First contact
We receive the request by email or phone and confirm the referral within 24 business hours.
- 02
Assessment at home
The coordinating nurse and, when needed, a social worker assess the patient at home, together with the referring professional.
- 03
Plan and quote
We send the care plan, the professionals involved, the quote and the travel cost for the municipality in writing.
- 04
Start and feedback
Care usually starts within 48 to 72 hours after the assessment, with a report back to the professional who referred the patient.
Send a referral
Choose whichever route suits you. We reply in Portuguese, English, French or Dutch.
Please do not send detailed clinical data in the first message. Information is collected afterwards, with the patient's consent and in line with GDPR.
Need to discuss a case before referring?
We can talk by phone or video call to see whether home care is the right answer and which professionals make sense.
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