Home Health Referral: A Discharge Planner’s Guide to Vetting and Partnering with Home Care Agencies

Score an Agency Before You Refer

Use this scorecard to score any home care agency before adding them to your referral list, or before routing a specific patient. The tool below turns the criteria experienced planners carry in their heads into a single number you can document.

Discharge planners arrange millions of home health episodes each year, but the quality data is thin. A 2023 study of 58 Michigan hospital discharge planners found that 90% wanted quality data on the agencies they refer to, and only 20% had it (Li et al., PMC, 2023). This scorecard fills that gap.

A score below 65 is a do-not-refer flag, not a final verdict. It tells you exactly which gaps to verify before a patient goes home. A green score above 85 means the agency clears every signal that maps to a clean handoff and a lower 30-day readmission risk.

What Makes a Home Health Referral Reliable?

A reliable home health referral rests on five measurable signals: active licensure, EVV compliance, CMS Care Compare star rating, referral acceptance speed, and documented 30-day readmission rate. Each one is checkable before you send a single patient.

The gap between what planners need and what they have is documented. A 2023 peer-reviewed study of 58 Michigan hospital discharge planners found that 90% wanted quality data on agencies and only 20% had it (Li et al., PMC, 2023). The same study found planners define agency quality first as visiting the patient quickly and second as preventing readmission.

Quality in home care, as discharge planners themselves define it, comes down to whether an agency shows up fast, keeps the patient stable, and answers the phone. Those three behaviors map cleanly onto the five signals below, which is why choosing a home care agency on these criteria beats choosing on reputation or habit.

• Active state license and Medicare certification, with no restrictions and no pending sanctions
• CMS Care Compare star rating of 3 or above, checked before every new referral
• EVV system in place, since it is federally mandated and non-compliant agencies are a red flag
• Referral acceptance within 2 hours, because agencies that take 4 or more hours have staffing constraints
• 30-day readmission rate shared proactively, since agencies that track this are invested in outcomes

The star rating is the fastest screen, but it is not the whole picture. A four-star agency that cannot accept a referral for six hours is still a poor fit for a patient discharging today. Pair the public rating with your own acceptance-time log and direct experience, and the home health care referral decision gets far more accurate.

These five signals feed directly into the scorecard above. Treat them as your pre-screen, then use the scorecard to capture the detail that no public rating captures, such as on-call coverage and a named clinical contact.

What CMS Requires You to Offer: Patient Choice Rules in Plain Language

Under 42 CFR 482.43, you must give every patient a list of home health agencies serving their area, and you must include both Medicare-certified and non-certified options if they exist, but you are not prohibited from indicating which agencies you have had positive experience with. That last point matters, because many planners wrongly believe sharing experience is banned.

The 2019 CMS final rule updated these requirements significantly. Hospitals must now document the patient's or caregiver's involvement in the planning process and provide quality data alongside the agency list (CMS Discharge Planning Final Rule, Federal Register Vol. 84, p. 51836, 2019). The role of a discharge planner in hospital settings now formally includes surfacing outcome data, not just names.

The line between a compliant list and improper steering is narrower than most medical discharge planner training covers. The table below separates what the rule requires from what it forbids, so you can route home care referral services with confidence.

Sharing your professional experience with an agency is not steering. The 2019 rule explicitly permits hospitals and planners to provide information about agency quality, including satisfaction scores and outcome data (42 CFR 482.43). Patients have the right to choose any willing and able provider, and giving them honest quality context helps them exercise that right well.

Plain-language compliance protects both the patient and your department. For the clinical transition steps your patients need once home, including medication reconciliation, the 30-day follow-up window, and LACE scoring, see our clinical transition checklist for the 30 days after hospital discharge.

How Home Care Agency Quality Affects Your Hospital’s Readmission Metrics

When a home care agency fails in the first 30 days through late starts, missed visits, or poor medication management, the patient often returns to your ED, and that readmission is counted against your hospital under the CMS Hospital Readmissions Reduction Program. The referral decision and the penalty are linked.

HRRP penalizes hospitals up to 3% of all Medicare base operating DRG payments for excess readmissions in six categories: heart attack, heart failure, pneumonia, COPD, hip or knee replacement, and CABG surgery. The penalty calculation uses three years of readmission data (CMS HRRP). A weak home health referral on any of those conditions raises your exposure directly.

The connection to your referral list is direct. Patients sent to low-quality home care agencies are more likely to deteriorate within 30 days. The 2023 study found planners themselves define agency quality first as visiting the patient quickly and second as preventing readmission (Li et al., PMC, 2023).

EVV compliance is a quality proxy because agencies that track visits accurately and submit on time are operationally disciplined. The 21st Century Cures Act mandated EVV for personal care and home health services, so a non-compliant agency signals deeper process gaps (AHRQ Discharge Planning Primer). For a hospital case manager, that one signal predicts a lot.

A skilled nursing referral carries the same logic. Whether the patient goes to home health or a higher level of post-acute care, the agency’s start speed and clinical capacity drive your readmission risk. For a full breakdown of EVV mandates by state and what agencies must capture, see our EVV compliance requirements for home care agencies.

The Handoff Workflow: What to Send a Home Care Agency at Discharge

A complete home health referral packet contains six elements: the physician’s signed plan of care (485 form), clinical summary, medication list, emergency contacts, insurance and payer information, and confirmed EVV activation date. Miss one and the agency cannot start clean care.

The 72-hour follow-up call is the most skipped step. AHRQ’s Re-Engineered Discharge (RED) protocol recommends a hospital-initiated follow-up call to the patient two to three days after discharge (AHRQ RED Toolkit). Most agencies do not make this call without prompting, so a nurse discharge planner who confirms it closes a real gap.

Agency capacity confirmation is a step many planners skip under time pressure. Confirm in writing that the agency has a caregiver available in the patient’s zip code for the expected start date (Patel & Bechmann, StatPearls, 2023). A referral the agency accepts but cannot staff is worse than a clean decline, because it eats the discharge window.

Modern scheduling tools make capacity confirmation faster. Agencies that run AveeCare’s caregiver scheduling and dispatch tools can confirm zip-code coverage and a start date in minutes rather than callbacks. For the full documentation home care agencies must maintain once care begins, including visit notes, care plan updates, and incident reports, see documentation home care agencies must maintain per CMS.

Red Flags: When to Remove an Agency from Your Referral List

Remove an agency from your active referral list when they show three or more of these eight warning signs, because one incident is a data point and a pattern is a liability. The signals below are all observable from your chair.

• Referral acceptance consistently takes more than 4 hours without explanation
• Start-of-care visit documented more than 48 hours after the agreed discharge date
• CMS Care Compare shows quality measures declining two consecutive quarters
• EVV submission rate below 90%, visible in Care Compare process measures
• Caregiver shows up without knowledge of the patient's care plan
• Agency has an active CMS sanction, civil money penalty, or complaint investigation
• State license expired or operating on a provisional license
• No 24/7 on-call number, voicemail-only after business hours

Removing an agency is not a punitive act, it is a quality management decision. Most planners informally stop referring to problem agencies without documentation, which leaves a gap if a referral is ever audited. A written referral-review policy protects your department and gives community home care referral services a consistent standard to meet.

State license verification takes under two minutes. Most state health departments publish an active home care agency license lookup tool online, and a quick check catches expired or provisional licenses before they become your problem. Check your state’s lookup in our state-by-state home care licensing requirements.

How to Use CMS Care Compare to Vet Any Home Health Agency

Medicare’s Care Compare tool shows every Medicare-certified home health agency’s star ratings across five quality domains, and it is free, updated quarterly, and takes under three minutes to use. It is the single most powerful public tool for vetting, yet only about a third of planners use it.

Care Compare is your baseline, not your ceiling. Pair it with your internal referral log tracking acceptance time and your own direct experience (CMS Home Health Star Ratings). The scorecard at the top of this guide synthesizes both into a single home health referral score for any decision.

Building Ongoing Referral Partnerships Beyond the One-Time List

Discharge planners with two or three trusted preferred-partner agencies spend less time on each handoff, field fewer post-discharge calls from patients, and post better HRRP outcomes, because the agency already knows your workflow. A cold list every time costs you more than it looks.

A preferred-partner relationship is built on four things: reliable communication, consistent performance data, shared digital access to care updates, and a direct clinical contact rather than just a billing department phone number. Transitional care management runs smoother when the agency is a known quantity.

Ask agencies what technology they use for care coordination. Agencies on modern platforms can share visit data automatically, so you know if the first visit happened on time without waiting for a callback. That visibility matters most for high-risk HRRP condition patients, where a missed first visit is the start of a readmission.

Real-time EVV data sharing

Agencies using AveeCare’s real-time EVV data sharing close the visibility gap faster than any callback process. AveeCare’s EVV dashboard for real-time visit verification lets agencies share visit verification data with referral partners immediately. It is one of the features discharge planners should ask about when building a preferred list of home care referral services.

For the agency-side perspective on how these partnerships get built, see how home care agencies build referral partnerships with discharge planning departments.

Frequently Asked Questions

Sources

• -Li J, et al. Hospital Discharge Planners Need More Information When Referring Patients to Home Health Care. PMC10637131. 2023.
• -CMS Discharge Planning Final Rule (2019). Federal Register Vol. 84, p. 51836.
• -42 CFR 482.43 - Conditions of Participation: Discharge Planning.
• -CMS Hospital Readmissions Reduction Program (HRRP). Accessed May 2026.
• -AHRQ Discharge Planning and Transitions of Care Primer. Accessed May 2026.
• -AHRQ Re-Engineered Discharge (RED) Toolkit. Accessed May 2026.
• -Patel PR, Bechmann S. Discharge Planning. StatPearls. Updated 2023.
• -CMS Home Health Quality Initiatives, Home Health Star Ratings. Accessed May 2026.