Home Health Referral Checklist for Hospital Discharge Planners and Case Managers

Written by Michael Thompson Registered Nurse, RN Jul 28, 2026

A reliable home health referral checklist helps discharge planners and case managers turn an inpatient or facility care plan into a safe, reviewable home health request. The goal is not simply to send a face sheet before discharge. The referral must connect the patient’s current condition to an ordered skilled service, document the homebound picture, identify the actual discharge location, and give the receiving agency enough information to evaluate the case.

HarvardCare Home Health reviews professional referrals for eligible patients within its approved Los Angeles County service area when Original Medicare Part A and Part B are primary. Every submission remains subject to coverage verification, provider documentation, current-agency status, clinical review, and service availability. A planned discharge date does not guarantee admission or a particular start-of-care time.

Identifying home health needs before discharge

Begin discharge planning early enough to identify what the patient will need between outpatient appointments. A patient may need skilled nursing at home for assessment, medication teaching, disease monitoring, ordered injections, or post-procedure follow-up. Other patients may need wound care, catheter or ostomy support, IV therapy, or a home-based therapy evaluation.

Document the change from baseline. Include the recent hospitalization, procedure, infection, fall, wound, medication change, weakness, or functional loss that prompted the referral. Describe what requires professional skill rather than listing “home health” as a general discharge service. If the primary need is supervision, meal preparation, transportation, companionship, or long-term personal care, explain that separately; those needs do not by themselves establish eligibility for Medicare skilled home health.

Before sending protected information, discharge teams can review the professional referral requirements and confirm the secure intake pathway.

Confirming the intended discharge location

The care address determines where the agency must send staff, not the address printed on an identification or insurance card. Confirm whether the patient is returning to a private residence, staying temporarily with family, moving to assisted living or board-and-care, or going to another post-acute setting. Include the unit number, gate or access details through an appropriate secure channel, and the best patient or representative contact.

Clarify who will be available at home, what language or communication support is needed, and whether there are safety concerns that may affect the first visit. Do not promise that a caregiver will be present unless that arrangement has been confirmed.

Confirming the Los Angeles County service area

HarvardCare serves its approved Los Angeles County service area. County residence alone does not confirm availability. Intake must review the exact address, requested discipline, clinical needs, and staffing. If the patient’s post-discharge address is uncertain, resolve it before representing the referral as ready.

Verifying Medicare coverage information

Provide accurate Medicare identifiers through the approved secure process, along with other insurance information and the patient’s demographic details. HarvardCare currently considers eligible patients when Original Medicare Part A and Part B are primary. This is HarvardCare’s present policy, not a universal requirement for every home health agency.

If the patient has Medicare Advantage, Medi-Cal, commercial coverage, hospice, or another program, state that accurately. Do not label a plan “Original Medicare” merely because the patient has a Medicare card. Intake must verify payer status and determine whether HarvardCare can consider the case.

Confirming homebound status

Medicare home health generally requires the patient to be homebound. Discharge documentation should explain why leaving home is medically inadvisable or requires another person, a supportive device, or special transportation, and why leaving normally takes considerable and taxing effort.

Useful details include assistance required for transfers or stairs, walker or wheelchair use, oxygen needs, severe weakness, exertional shortness of breath, cognitive or behavioral barriers, weight-bearing restrictions, pain, and fall risk. A patient may leave home for medical care and occasional brief absences; the analysis depends on the full pattern and individual condition.

Identifying the skilled service requested

Name the discipline and clinical purpose. “RN for wound assessment and ordered dressing changes” is more actionable than “evaluate.” “PT for new gait and transfer decline after hospitalization” is clearer than “weakness.” When multiple disciplines are requested, explain the need for each.

Common post-discharge services include physical therapy, occupational therapy, and speech therapy. Services and visit frequency depend on eligibility, the authorized plan of care, clinical assessment, and ongoing need.

Obtaining provider orders

Identify the physician or allowed practitioner responsible for ordering home health and overseeing the plan. CMS permits physicians and certain allowed practitioners—including nurse practitioners, clinical nurse specialists, and physician assistants—to order and certify home health, subject to applicable requirements. The discharge planner may coordinate transmission but should not imply that coordination replaces practitioner authorization.

Make orders specific enough to evaluate and implement safely. Include discipline, diagnosis or reason, relevant treatments, precautions, frequency instructions when required for a procedure, and the provider’s contact information. If a signature or order is pending, state the status and expected responsible office rather than sending an incomplete packet without explanation.

Gathering discharge records

A focused discharge packet should include the final or most current discharge summary, history and physical, recent progress notes relevant to the home health need, procedure or operative reports, consultation notes, applicable labs, and follow-up plans. Include the face-to-face documentation supporting the home health certification when it is part of the facility record.

Send the record that explains the present need. Large undifferentiated chart exports can hide the order and current plan. If preliminary records are sent before discharge, follow up with final orders and medication reconciliation rather than assuming the first packet remains accurate.

Medication reconciliation information

Send a current discharge medication list with doses, routes, frequencies, allergies, and clear indications of starts, stops, or changes. Identify high-risk transitions, anticoagulants, insulin, antibiotics, injections, infusions, and laboratory or symptom monitoring orders. Note the responsible pharmacy and infusion provider when applicable.

If medication teaching or monitoring is the skilled reason for referral, explain the observed deficit or risk. HarvardCare’s in-home medication management supports an ordered skilled plan; it is not a substitute for pharmacy dispensing or continuous medication administration.

Wound, catheter, ostomy, IV, and therapy documentation

Wounds

Include wound location, type or suspected etiology, measurements, tissue and drainage findings, surrounding skin, infection concerns, current dressing protocol, frequency, recent procedures, cultures when relevant, pressure relief or offloading, and provider follow-up. Link orders to the clinical record and use non-graphic secure documentation when images are clinically necessary.

Catheters and ostomies

For catheter care at home, provide device type, size, insertion or change date, reason, maintenance or change orders, supplies, and complications. Ostomy referrals should identify ostomy type, surgery date, appliance, peristomal concerns, teaching needs, and surgeon or ostomy-clinic plan.

IV therapy

For IV therapy at home, include medication, dose, route, frequency, planned duration, vascular access type, line-care orders, laboratory monitoring, pharmacy, delivery arrangements, and the provider responsible for adverse events and order changes.

Therapy

Include prior level of function, current mobility and ADL status, assistance needed, equipment, precautions, cognition, communication or swallowing findings, weight-bearing status, and therapy recommendations. If outpatient therapy is planned concurrently, clarify the intended arrangement.

Confirming whether another home health agency is active

Ask the patient, representative, facility record, and payer information whether another agency is currently serving the patient. Medicare home health is generally managed through one elected agency at a time. If a transfer is intended, provide current agency details and coordinate the appropriate discharge or transfer process.

Coordinating the requested start-of-care date

Provide the expected discharge date and time, when the patient will physically arrive home, immediate treatment deadlines, upcoming appointments, and patient availability. For time-sensitive medications, wound treatments, or device needs, confirm that the hospital or facility has provided a safe bridge plan and necessary supplies. Do not discharge based on an assumption that a submitted referral equals acceptance.

HarvardCare Home Health cannot guarantee a start-of-care time. Intake must complete its review and the patient must be available with required orders, records, medications, equipment, and a safe plan.

Avoiding preventable admission delays

• Use the actual discharge address and working contact numbers.
• Send the final signed order and identify the practitioner who will follow the plan.
• Describe homebound limitations and skilled need with patient-specific facts.
• Reconcile medications and resolve conflicting treatment instructions.
• Include discipline-specific wound, IV, catheter, ostomy, or therapy information.
• Disclose an active home health agency and clarify any intended transfer.
• Do not wait until the patient is already home to identify missing equipment or supplies.
• Use secure channels and respond promptly to intake clarification.

Printable-style home health discharge referral checklist

Patient and destination

• ☐ Full demographics and secure contact information
• ☐ Exact discharge address, unit, city, and ZIP code
• ☐ Confirmed discharge date, arrival time, and responsible contact
• ☐ Language, communication, mobility, and access considerations

Eligibility and coverage

• ☐ Original Medicare Parts A and B status and other payer details
• ☐ Patient-specific homebound documentation
• ☐ Current home health agency, hospice, or overlapping service status

Orders and clinical record

• ☐ Ordering practitioner and office contact
• ☐ Signed discipline-specific orders or clearly documented pending status
• ☐ Face-to-face note and relevant recent clinical documentation
• ☐ Final discharge summary and current diagnoses
• ☐ Reconciled medication and allergy list
• ☐ Wound, device, infusion, or therapy instructions and precautions

Transition readiness

• ☐ Equipment, medications, dressings, and immediate supplies arranged
• ☐ Patient or representative informed that referral is under review
• ☐ Follow-up appointments and responsible providers identified
• ☐ Referral transmitted through the secure professional referral form

For additional process detail, review how to refer a patient for home health care and the patient-facing guide to PT, OT, and speech therapy after a hospital stay.

Frequently asked questions

When should discharge planning for home health begin?

Begin as soon as a likely skilled need and home discharge plan are identified. Early work allows time to confirm coverage, location, orders, documentation, equipment, and agency availability without treating a tentative plan as an accepted admission.

Can a case manager sign the home health order?

Case managers can coordinate and transmit referrals, but they should not be assumed to have authority to order or certify Medicare home health. The order must come from an authorized physician or allowed practitioner under applicable requirements.

Should the packet include the entire hospital chart?

Usually a focused, current packet is more useful. Send the order, face-to-face support, discharge summary, medication list, and records relevant to the skilled need, then provide additional documents if intake requests them.

What if the discharge address changes?

Notify intake immediately. The new address may affect service-area and staffing review, and the agency needs accurate access and contact information before confirming next steps.

Can home health replace a safe discharge plan?

No. Home health visits are intermittent and admission is not automatic. The facility remains responsible for an appropriate discharge plan, including immediate medications, equipment, supplies, transportation, caregiver arrangements, and emergency instructions.

What if the patient needs a wound dressing the evening of discharge?

Coordinate a safe bridge plan before discharge. Do not assume a new agency can perform a same-day visit. Provide clear orders, supplies, timing, and contingency instructions while intake determines eligibility and availability.

Can a patient receive outpatient therapy and home health therapy together?

The arrangement requires review because coverage, duplication, homebound status, and care coordination may be affected. Disclose all active therapy services so the agency and ordering practitioner can evaluate the plan.

Does a requested start date guarantee a visit?

No. The date communicates clinical and transition needs, but timing depends on complete orders, eligibility, patient readiness, service area, clinical review, and staffing. Wait for explicit acceptance and coordination.

Where can discharge teams confirm Medicare requirements?

Use Medicare.gov’s official home health information and current CMS manuals. HarvardCare’s intake team can explain agency requirements but cannot guarantee coverage.

Coordinate a professional post-discharge referral