After a hospital orders or recommends home health, the referral goes to an agency for review. The agency confirms the skilled need, orders, supporting documentation, eligibility, coverage, staffing, service area, and whether the care can be provided safely at home. If accepted, the agency coordinates an initial visit and the plan of care with the ordering provider.
A hospital order is important, but it does not by itself guarantee agency admission, Medicare coverage, or a particular start date.
Before the patient leaves the hospital
Patients and families should know:
- which provider will follow the patient after discharge;
- which home health agency received the referral;
- which nursing, therapy, or other disciplines were requested;
- what medications changed and which list is current;
- what equipment and supplies must be in the home;
- which wound, activity, diet, or safety instructions apply; and
- which symptoms require a call, urgent evaluation, or emergency care.
Keep the discharge instructions, medication list, provider contacts, follow-up appointments, and equipment information together. If instructions conflict or are unclear, contact the discharge team or prescribing clinician instead of guessing.
The agency reviews the referral
Intake may contact the hospital, ordering provider, patient, family, or health plan to clarify missing information. Review commonly considers:
- the current clinical and functional picture;
- the skilled service being requested;
- provider assessment, orders, and supporting notes;
- payer requirements and authorization;
- patient location and current service availability; and
- whether the home setting can support safe care.
The agency should explain what information is still needed and how to share it securely. Protected health information should not be sent through an ordinary website form or unsecured email.
If the referral is accepted
The agency arranges the initial contact and visit according to the individual referral, orders, and applicable requirements. Medicare.gov notes that the home health agency schedules an appointment to discuss the patient’s needs and communicates with the provider about the care plan.
The exact timing depends on the case. A website should not promise same-day, next-day, or another start-of-care timeframe without confirmed operational support.
What may happen during the first visit
The clinician may:
- verify the patient’s identity, orders, and current information;
- assess needs within the clinician’s discipline;
- review medications and discharge instructions;
- evaluate safety, mobility, equipment, or supplies;
- explain the ordered plan and visit expectations;
- teach the patient or caregiver what to monitor; and
- identify changes that should be communicated to the ordering provider.
The first visit is also a good time to ask who to call during office hours, after hours, and in an emergency.
Prepare the home for the first days
Clear the walking route, place commonly used items within reach, keep equipment available, and write down questions. Do not make unapproved medication, wound-care, diet, activity, or equipment changes.
Depending on the order, skilled nursing may support assessment, teaching, or ordered care, while physical therapy at home may address walking, transfers, balance, stairs, and safe device use. The post-hospital care page brings these pieces together.
For the step before this one, read how to get a home health referral. For Medicare-specific requirements, review who qualifies for Medicare home health.
This article provides general education and does not replace individualized medical advice, discharge instructions, or emergency care. Follow the patient’s written escalation plan and call 911 for an emergency. Contact intake for referral-process questions.