A Clearer Hand-off into Home Health.
Care coordination should continue after discharge.
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Clear Intake
Focused review of referral information and service needs.
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Coordinated Clinical Care
Disciplines aligned around one plan of care.
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Meaningful Documentation
Progress and changes documented around clinical relevance.
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Patient Education
Clear teaching that supports continuity between visits.
A simple path from referral to start of care.
Intake review
Referral Received
Start of care
Clinical Coordination
Expert Facilitation
Ongoing Communication
Services designed to support recovery at home.
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Assessment, monitoring, education, and ordered clinical interventions.
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Mobility, balance, strength, endurance, and fall-risk reduction.
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Daily function, adaptive strategies, and independence.
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Communication, cognition, swallowing, and participation.
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Resource coordination and barrier support.
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Authorized personal-care support under clinical direction.
Help us move the referral forward efficiently.
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Basic identifying and contact information needed to begin intake.
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Relevant diagnoses, recent changes, and background that help us understand the patient’s current needs.
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Orders that identify the home health services requested and support the plan of care.
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Recent hospital, rehabilitation, or facility records that provide context for the transition home.
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A current list of prescribed medications to support safe clinical review and patient education.
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Current coverage details needed for eligibility and benefit verification.
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The skilled services being requested, such as nursing, physical therapy, occupational therapy, or speech therapy.
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Current provider details so our team can coordinate orders, questions, and clinically relevant updates.