Wound Care
Who can refer a patient to home health care? The practical answer has two parts. Many professionals can identify a possible skilled need, communicate it to a home health agency, and help assemble the referral. A narrower group of authorized practitioners can issue, sign, and certify the medical orders and Medicare documentation required for care.
Keeping those roles distinct helps Los Angeles County referral partners act promptly without overstating their authority. HarvardCare Home Health welcomes referral coordination from licensed providers, medical offices, hospitals, facilities, social services professionals, care managers, home-care organizations, and paid professional caregivers. Every request remains subject to provider orders, coverage and homebound review, skilled need, service area, current-agency status, clinical appropriateness, and availability.
Who can refer a patient to home health care or communicate a need?
Anyone involved professionally in a patient’s care may notice a change that warrants review: a worsening wound, medication-management problem, post-hospital decline, unsafe transfers, a new catheter, an ordered infusion, or difficulty attending outpatient services. Referral sources can describe that concern, provide contact and location information, and connect HarvardCare Home Health with the responsible provider.
Professionals who are ready to coordinate the request may begin a home health referral. The submission starts intake review and does not independently authorize services or guarantee admission.
Physicians
Physicians commonly identify the skilled need, order home health disciplines, support homebound and medical-necessity documentation, and oversee the plan of care. Primary care physicians, hospitalists, surgeons, podiatrists, vascular specialists, wound-care physicians, and other treating physicians may participate when the requested service relates to their evaluation and applicable scope.
A useful physician referral includes a current clinical note, diagnosis, patient-specific findings, requested discipline, treatment orders, and provider-office contact information. For a wound or procedure, include the specific treatment plan and relevant precautions rather than only “home health evaluate.”
Nurse practitioners
CMS recognizes nurse practitioners as allowed practitioners who may order and certify Medicare home health, subject to federal and state requirements. An NP may evaluate the patient, document the face-to-face encounter, establish or review the plan, and coordinate with the home health agency when authorized.
Referral teams should still ensure that the NP’s note supports the present homebound and skilled-need picture and that the order is complete. A professional title alone does not replace patient-specific documentation.
Physician assistants
Physician assistants are also included among CMS allowed practitioners for ordering and certifying home health, subject to applicable requirements. A PA can provide relevant encounter documentation and orders when acting within the required scope and relationship.
Medical offices should identify the practitioner who will respond to plan-of-care questions and future order requests. The agency needs a reliable clinical contact, not merely the name of a practice.
Medical office staff
Referral coordinators, medical assistants, nurses, and administrative staff often assemble and securely transmit the packet. They can confirm demographics, coverage, provider contact, records, and order status. They should not sign or certify documents unless independently authorized to do so.
A well-organized office submission includes the actual signed order or clearly states that it is pending. It also identifies the relevant recent encounter note, medication list, and specialty instructions. Review the detailed home health referral requirements before sending the packet.
Hospital case managers
Case managers can identify discharge needs, discuss agency options, coordinate records, and connect the receiving agency with the ordering practitioner. They are often central to arranging post-hospital nursing at home and therapy services.
The case manager should confirm the actual discharge address, timing, payer information, homebound circumstances, skilled discipline, equipment and supply plan, and whether another agency is active. The facility should not treat referral transmission as confirmation that the patient has been accepted.
Discharge planners
Discharge planners coordinate the transition from inpatient or post-acute care to home. They can send orders, discharge summaries, medication reconciliation, procedure records, therapy recommendations, and discipline-specific instructions. A structured home health referral checklist for discharge planners can reduce preventable delays.
Social workers
Hospital, facility, clinic, and community social workers may identify barriers and communicate a possible skilled need. They can help clarify the patient’s living situation, support system, transportation limitations, responsible contacts, and resource concerns. Home health medical social work may also be ordered as part of an eligible plan; see medical social work at home.
A social worker’s referral does not replace an authorized medical order. The social worker can help connect the patient with the practitioner who will evaluate and document the need.
Skilled nursing and rehabilitation facilities
SNFs and rehabilitation facilities can coordinate referrals when a resident is transitioning to a community setting and may need intermittent skilled follow-up. Send final discharge orders, recent nursing and therapy information, medication reconciliation, wound or device records, equipment needs, and the confirmed home address.
Facility-level care needs do not automatically translate to a Medicare home health plan. The receiving agency must determine whether the patient meets homebound and skilled-need requirements and whether the ordered services can be delivered safely on an intermittent basis.
Assisted living and board-and-care communities
Community staff may notice a new wound, fall, functional decline, medication change, or other skilled concern. They can initiate communication with HarvardCare and the patient’s provider, identify the residence and responsible party, and explain what support the community does and does not provide.
Living in assisted living or board-and-care does not automatically qualify or disqualify a patient. Intake reviews the individual’s residence, homebound circumstances, skilled need, orders, coverage, and existing services.
Wound-care, podiatry, and vascular practices
Specialty practices can refer patients who need ordered wound care at home between clinic visits. Include current wound assessment, location and type, measurements, clinical findings, dressing and treatment orders, frequency, diagnoses, procedure notes, offloading or compression instructions, and the provider responsible for changes.
Home health nursing complements rather than replaces specialty follow-up. The plan should explain how the home health nurse and clinic will communicate about changes.
Geriatric care managers
Professional care managers can recognize changes, organize information, obtain patient or representative permission, and coordinate among family, providers, facilities, and the home health agency. They can communicate the referral but cannot independently issue Medicare medical orders unless they separately hold appropriate authority as an allowed practitioner.
Home-care agencies
Non-medical home-care staff often observe patients frequently and may notice a wound, medication problem, fall, respiratory change, or decline in mobility. The agency can alert the patient’s provider and submit a professional referral for review.
Non-medical care and Medicare home health serve different purposes. HarvardCare Home Health provides intermittent skilled services under a provider-directed plan; it does not provide private-pay, live-in, custodial, companion, or stand-alone non-medical caregiver services.
Paid professional caregivers
A paid caregiver can report objective observations and help connect the patient, representative, provider, and intake team. Useful observations include a new inability to transfer, repeated falls, difficulty following a new medication regimen, drainage through a dressing, or problems with a catheter. Emergencies require emergency services, not a website referral.
The caregiver should avoid diagnosing, changing treatment, or implying that a referral authorizes care. An authorized practitioner must evaluate and order the appropriate skilled service.
Making a referral versus issuing or certifying an order
A referral communicates a possible need and supplies information for agency review. An order directs the medical service. Medicare certification attests to required eligibility elements and is tied to provider documentation, including the applicable face-to-face encounter. These functions can overlap when the referring person is the authorized practitioner, but they should not be treated as interchangeable.
CMS recognizes physicians, nurse practitioners, clinical nurse specialists, and physician assistants as allowed practitioners for home health ordering and certification under applicable rules. State law, scope, documentation, and Medicare requirements still matter. A social worker, case manager, caregiver, or administrative coordinator may be essential to the referral while not being the person who signs the medical order.
What information should the referral source provide?
- Professional name, role, organization, phone, and secure contact information
- Patient demographics, actual Los Angeles County service address, and responsible contact
- Original Medicare status and other payer information
- The specific skilled concern and discipline requested
- Patient-specific homebound and functional information
- Ordering practitioner and office contact details
- Order and face-to-face documentation status
- Recent clinical records, medications, and discipline-specific instructions
- Current home health agency or overlapping service status
- Discharge date or requested timing, without representing it as guaranteed
HarvardCare reviews the exact service location against its approved Los Angeles County service-area directory. Relevant services may include skilled nursing, physical therapy, and occupational therapy, subject to eligibility and orders.
Frequently asked questions
Can a social worker make a home health referral?
Yes. A social worker can identify a need, coordinate the referral, and provide relevant information. The social worker’s request does not replace the order and certification required from an authorized practitioner.
Can a caregiver refer a patient to home health care?
A paid professional caregiver can begin communication and report observed needs. The provider must still evaluate and order appropriate care, and the agency must complete eligibility and admission review.
Can a physician’s office send the referral without the physician calling?
Yes. Authorized office staff can securely transmit the packet and coordinate follow-up. The actual orders and required provider documentation must still be completed by an appropriately authorized practitioner.
Can an assisted living community request home health?
Yes. Community staff can initiate a referral for a resident with a possible skilled need. Residence in the community does not by itself establish Medicare eligibility or agency acceptance.
Can a wound clinic continue seeing the patient?
Often specialty follow-up and home health can be coordinated when medically appropriate. The clinic and home health agency should have clear orders, roles, communication, and plans for treatment changes.
Who certifies homebound status?
The Medicare home health certification is completed by a physician or allowed practitioner, supported by the medical record. The home health agency also evaluates the patient and documentation as part of admission and ongoing care.
Does the referral source choose the visit frequency?
Orders and clinical information inform the plan, but visit frequency depends on authorized orders, assessment, reasonable and necessary care, the plan of care, and ongoing clinical need. A referral cannot guarantee frequency.
Can HarvardCare accept a referral for companionship only?
No. HarvardCare does not provide private-pay, live-in, custodial, companion, or non-medical caregiver services. The patient must have a qualifying skilled home health need and satisfy the applicable review criteria.
Does submitting the form mean the patient is admitted?
No. The form starts a review of coverage, location, homebound status, skilled need, documentation, current agency status, clinical appropriateness, and availability.
Where can professionals review official practitioner rules?
See current CMS home health guidance and CMS’s Home Health PPS information, which describes allowed practitioners. Consult current requirements for the individual situation.
Start a professional referral
If you have identified an eligible homebound patient who may need skilled services in Los Angeles County, gather the provider and clinical information and submit a professional home health referral to HarvardCare Home Health.
Understanding who can refer a patient to home health care helps each professional contribute without replacing the authorized practitioner’s role.
Submission starts eligibility and documentation review; it does not guarantee admission, Medicare coverage, service availability, visit frequency, or timing.
