Get known by hospital discharge planners
Hospitals were the referral source on 37% of Medicare home health stays in 2024. Behind each one is a discharge planner or case manager who had to find an agency that would say yes, fast. You want to be one of the names they already know.
What their week looks like
A discharge planner carries a caseload that turns over every few days. Every patient going home with needs gets a plan, and every plan needs an agency that will accept the case, confirm insurance, and start care on time.
When the discharge is at two o'clock and the first three agencies on the list don't call back, the planner keeps dialing. The agency that answers, gives a straight yes or no, and starts care when it said it would is the agency they remember.
Hospitals have to give patients a choice of agencies, and the list only includes Medicare agencies that serve the area and have asked to be listed. Being known doesn't skip that list. It means that when a patient asks which agency is good, or the planner needs someone who will take a hard case, your name comes up.
- Titles we target
- Discharge Planner · RN Case Manager · Care Transitions Coordinator · Transition of Care Nurse · Utilization Review Nurse
- Where they work
- Acute care hospitals, community hospitals, academic medical centers
- Best fit for
- Home healthHome careHospice
What they need from an agency
Your first conversations should make these clear. If one of them isn't true yet, fix it before outreach starts.
A fast yes or no
They need to know within the hour whether you can take the case. A slow maybe is worse than a no.
Start of care you keep
Medicare requires the first nursing visit within 48 hours of referral or the return home, unless the doctor orders a date. Planners notice who keeps it.
On the hospital's list
Hospitals only list agencies that have asked to be listed. Make sure you've asked, in writing, at every hospital you serve.
One number that answers
A direct line to someone who can say yes, including Friday at 4 pm. Planners keep the numbers that work.
What goes out from your profile
The first message is about their unit and their patients, never about your agency's awards. One line says who you are. The question asks how they handle care at home today.
First message · example
thanks for connecting. you spent years as a telemetry nurse before moving into case management, and now you handle discharges for the cardiac floor at a community hospital. i run a home health agency here in Columbus. when a heart failure patient is going home and needs nursing visits, do you have a few agencies you usually call first?
Follow-up · 3 days later
no rush. if you ever need another agency that can start care quickly in Franklin County, happy to be one.
Other referral partners we reach
- Case managers & social workersCase management leaders and medical social workers who handle the hardest discharges.
- Skilled nursing & rehabSocial services and admissions teams who send every short-term rehab patient home.
- Physician practicesPractice managers and referral coordinators who decide where the home health order goes.
- Senior livingAssisted and independent living leaders whose residents need more help than the community provides.
- Hospice & palliativeHospice liaisons, intake teams, and palliative social workers who see families needing more help at home.
- Payers & care coordinationManaged care, Medicare Advantage, and Medicaid waiver care coordinators who assign services at home.
- Elder law & care managersElder law attorneys and aging life care managers who advise families before care starts.
Be the agency the planner already knows
On the audit we count the discharge planners in your service area who are on LinkedIn and pick the first ones to reach. Thirty minutes, free.