How to Refer a Patient for Home Health Care in Los Angeles County

Written by Patricia Santos Patient Care Coordinator Jul 28, 2026

Knowing how to refer a patient for home health care can prevent avoidable gaps when a patient is leaving a hospital, struggling to attend outpatient care, or developing a skilled need at home. In Los Angeles County, a referral may begin with a physician, allowed practitioner, case manager, social worker, facility team, medical office, or professional caregiver. The referral starts a review; it does not by itself establish Medicare eligibility or guarantee admission.

HarvardCare Home Health reviews each request for the patient’s location, current coverage, homebound circumstances, skilled need, provider documentation, current home health agency status, and the agency’s ability to meet the ordered needs. This guide explains what professional referral partners should prepare and how the process differs from the provider order and certification Medicare requires.

When a patient may need home health

A useful referral begins with a specific clinical or functional concern. A patient may warrant review after hospitalization, surgery, a new or worsening wound, a medication change, a fall, a decline in mobility, difficulty managing a catheter or ostomy, or a need for ordered IV therapy. The common question is whether intermittent skilled services are medically necessary and can be delivered safely in the home.

Examples include a patient who needs a nurse to assess an unstable condition, perform ordered wound care, teach a new medication regimen, or monitor a recent discharge plan. A patient may need physical therapy at home for gait and transfer problems, occupational therapy for safe daily activities, or speech therapy at home for an ordered communication or swallowing need.

Home health is not continuous supervision or non-medical caregiving. HarvardCare Home Health does not provide private-pay, live-in, custodial, companion, or non-medical caregiver services. Home health aide support may be included only when it is appropriate within an eligible skilled plan of care.

Who may initiate a home health care referral?

Many professionals may identify a need and communicate it to a home health agency. Physicians, nurse practitioners, physician assistants, medical office staff, hospital case managers, discharge planners, social workers, skilled nursing or rehabilitation facilities, assisted living teams, wound clinics, podiatry and vascular practices, geriatric care managers, home-care agencies, and paid professional caregivers can begin or coordinate a referral.

That broad ability to communicate a need is different from authority to order and certify Medicare home health. A professional caregiver, social worker, or facility coordinator can submit a professional home health referral, but the required order and supporting medical documentation must come from an appropriately authorized provider. CMS recognizes physicians and certain allowed practitioners, including nurse practitioners, clinical nurse specialists, and physician assistants, for home health ordering and certification, subject to applicable federal and state requirements.

Initiating a referral is not the same as providing the order

A referral source tells the agency that a patient may need evaluation for skilled home health and supplies the information available to support review. The provider order directs the services being requested. Medicare certification addresses the beneficiary’s eligibility for the home health benefit, including the homebound and skilled-need elements and the face-to-face encounter requirements.

Those steps may be coordinated by different people. For example, a discharge planner may send the referral packet while the hospitalist or other allowed practitioner completes the order and face-to-face documentation. A podiatry office may provide wound orders and clinical notes while a case manager confirms the discharge address and requested start-of-care date. The agency then evaluates the record and determines whether it can accept the patient.

Basic Medicare eligibility considerations

Medicare states that eligible home health patients generally must be under the care of a physician or allowed practitioner, need part-time or intermittent skilled services, and be homebound. Services must be furnished by a Medicare-certified home health agency under an established plan of care. The patient’s individual record—not a diagnosis alone—must support the need.

HarvardCare Home Health currently considers eligible referrals when Original Medicare Part A and Part B are primary. That is HarvardCare’s current intake policy, not a rule that applies to every home health agency. Other agencies may participate in different networks or accept other coverage. Referral partners should provide accurate coverage information so the correct pathway can be identified early.

Homebound status

Homebound does not mean that a patient is never permitted to leave home. Medicare describes a two-part standard: because of illness or injury, leaving home is not recommended or requires supportive devices, special transportation, or another person’s help; and the patient normally cannot leave home without considerable and taxing effort. Permitted medical trips and occasional short absences do not automatically eliminate homebound status.

Useful documentation describes the patient’s actual limitations. “Weak” is less informative than noting that the patient needs a walker and one-person assistance, cannot safely manage exterior steps, becomes markedly short of breath, or requires special transportation. The provider and agency make the applicable determinations based on the full record.

Qualifying skilled need

The referral should connect the patient’s condition to an intermittent skilled service. Examples include skilled nursing at home for assessment and teaching, home wound care under provider orders, therapy for a documented functional deficit, or IV therapy at home when clinically appropriate. Personal care alone, housekeeping, companionship, transportation, or meal help does not establish a Medicare skilled need.

Provider documentation that supports referral review

The most useful packet explains why home health is needed now. Depending on the situation, it may include:

• A signed home health order or clear information about the provider who is preparing it
• A recent face-to-face note, discharge summary, history and physical, or relevant progress note
• Current diagnoses and the clinical reason for the requested discipline
• An up-to-date medication list, allergies, and recent medication changes
• Functional and homebound information, including equipment or assistance required
• Wound measurements, treatment orders, procedure notes, or therapy precautions when applicable
• The patient’s discharge location, contact information, coverage details, and requested timing
• The name of any home health agency currently serving the patient

Only send protected health information through an authorized secure channel and only as permitted for treatment and care coordination. Do not place patient information in ordinary public website messages or unsecured email.

How HarvardCare Home Health reviews a referral

Intake first confirms that the patient will receive care within HarvardCare’s approved Los Angeles County service area. The team reviews Original Medicare status, whether another agency is active, the homebound picture, the requested skilled discipline, provider documentation, clinical appropriateness, staffing and service availability.

If key information is missing, intake may contact the referral source or provider office. The agency may also need clarification of orders, recent records, discharge timing, wound protocols, medication information, or the practitioner who will oversee the plan. Submission begins this review; it is not confirmation of eligibility, coverage, acceptance, visit frequency, or a start-of-care date.

Common reasons referral review is delayed

• The discharge address, phone number, or responsible contact is incomplete.
• The coverage information is unclear or indicates a payer HarvardCare does not currently accept.
• The order names “home health” but does not identify the requested skilled service or clinical reason.
• The face-to-face note or recent clinical record does not support the homebound or skilled-need statements.
• Wound, infusion, catheter, or therapy instructions are missing or internally inconsistent.
• The patient is still active with another home health agency and discharge or transfer status is unresolved.
• The requested timing is not aligned with the actual discharge date or patient availability.

Referral partners can reduce back-and-forth by sending a concise, current packet rather than a large record with no clear order or recent clinical narrative.

How to refer a patient for home health care: step by step

1. Identify the skilled concern. State the clinical change, recent event, or functional problem that may require nursing or therapy.
2. Confirm the intended home location. Provide the exact Los Angeles County address where services would occur.
3. Review basic eligibility indicators. Confirm coverage, homebound circumstances, and whether another home health agency is active.
4. Coordinate the provider order. Identify the ordering physician or allowed practitioner and whether the order is complete or in process.
5. Gather supporting records. Include recent notes, discharge material, medications, and discipline-specific instructions.
6. Use the secure intake pathway. Complete HarvardCare’s professional home health referral form without placing PHI in an unsecured channel.
7. Respond to clarification requests. Help intake obtain missing orders or records promptly.
8. Wait for the admission determination. Do not represent the patient as accepted until HarvardCare confirms its decision.

Professional referral checklist

• Referral-source name, role, organization, phone, and secure contact method
• Patient name, date of birth, contact, address, city, and ZIP code
• Original Medicare details and other coverage information
• Specific skilled service requested and clinical reason
• Homebound limitations described in practical terms
• Ordering provider and provider-office contact information
• Order status and applicable face-to-face documentation
• Recent clinical, discharge, medication, wound, or therapy records
• Current home health agency status
• Discharge date or requested start-of-care timing

For a broader patient-facing explanation of the benefit, see how to get Medicare home health services. Referral partners who need a documentation-focused review can also use the home health referral requirements guide.

Frequently asked questions

Can a case manager refer a patient to home health?

Yes. A case manager can initiate and coordinate a home health care referral, supply available records, and connect the agency with the ordering provider. The case manager’s referral does not replace the order, certification, or documentation required from an authorized practitioner.

Can a professional caregiver begin a referral?

A paid professional caregiver or home-care agency may alert HarvardCare Home Health to a possible skilled need and submit referral-source information. An allowed practitioner must still provide the required medical order and supporting documentation, and the patient must pass agency review.

Does the patient need to be completely unable to leave home?

No. Medicare’s homebound standard allows certain medical trips and occasional short absences. The record should show why leaving home generally requires help, equipment, special transportation, or considerable and taxing effort.

Does a referral guarantee Medicare coverage?

No. A referral starts an eligibility and documentation review. Coverage depends on applicable Medicare requirements and the individual record, while admission also depends on clinical appropriateness, orders, service area, current agency status, and HarvardCare’s capacity.

Can a patient receive home health from two agencies?

Generally, one home health agency manages the Medicare home health episode at a time. If another agency is active, intake must clarify discharge, transfer, or election status before a new admission can proceed.

What if the provider order is still pending?

The referral may be submitted with accurate order-status information, but services cannot proceed without the required authorized orders and supporting documentation. Include the provider’s contact details so intake can coordinate appropriately.

How quickly will care begin?

No start-of-care time can be guaranteed from the referral alone. Timing depends on discharge readiness, complete orders and records, eligibility, clinical needs, patient availability, service area, and agency staffing.

Can HarvardCare provide only bathing or companionship?

No. HarvardCare Home Health does not provide private-pay, live-in, custodial, companion, or non-medical caregiver services. Aide services, when appropriate, are part of an eligible skilled home health plan rather than a stand-alone companionship service.

Where can referral partners verify Medicare rules?

Use the official Medicare home health services page and current CMS manuals for federal guidance. HarvardCare can explain its intake requirements but does not make a universal coverage promise.

Refer an eligible patient to HarvardCare Home Health