Enriching lives in the communities we serve

Health Care Providers Making a Referral or With Service Questions Call: 888-525-7742

If you are a Family Member or Loved One With Questions about Home Care Call: 888-660-5772

Hospital Discharge

How It Works?

Each of our eight branches utilizes the same consistent guidelines and procedures for handling your inquiry or taking a referral for home health care. Referrals are usually initiated with a phone call to one of our branch offices from a hospital social worker, discharge planner, family member or from your primary care physician. Very often referrals are faxed to our branch office from the discharging hospital and will include a physician’s order and other necessary personal and clinical history information for the potential new home care client.

What You Can Expect?

A RN Case Manager will review all information provided from the referring party and follow-up, as needed, with the discharging hospital or facility to ensure all necessary paperwork and information is provided to complete a free home care assessment.

The Comprehensive Assessment – The RN Case Manager will contact the new client or responsible Third Party at the hospital, facility or in the home (if already discharged) to schedule the free assessment. If the client accepts care, our Case Manager will utilize a hand-held computer device to admit the client to home care and open a new client or patient chart. Insurance coverage information and other documents will be requested to complete the assessment and to develop a plan of care specific to each client’s care needs or desires. This process can take up to two hours and questions will need to be answered by the client or a responsible family member during the assessment.

Plan of Care – A Plan of Care will be developed by the Case Manager from information gathered during the referral, assessment and admission process, including documentation collected from discussions with the client and/or family members. The Plan of Care will establish the various cares to be provided, frequency and the skill level needed from caregivers. Caregivers involved may be a mix of skilled nurses, home health aides, therapists or other personal assistants.

We invite you to visit our Frequently Asked Questions (FAQ) to possibly address and answer any of your questions.   

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