Consider one first night at home. The referral reached the home care agency. The agency staffed a caregiver. Then the caregiver arrived. The patient could not transfer without two people, the hospital bed had not been delivered, and the daughter did not know the new medication schedule. Each organization did its own job. The patient still had a bad first night.
In that example, the missing facts existed at discharge and never reached the caregiver walking in the door. This guide lists what a home care agency needs in the referral to plan the first shift.
| What the agency needs | Why it changes the first shift |
|---|---|
| Discharge date and expected arrival time | Sets the start time and first-day coverage. |
| Mobility and transfers | Determines the transfer support required. |
| Cognition and behavior | Shapes supervision hours and caregiver experience. |
| Equipment delivery status | Confirms essential equipment is there before the shift begins. |
| Family decision-maker and phone number | Gives the agency one clear contact for the plan. |
The questions families cannot answer
Families may not know the answers to the clinical questions in the table, even when a family member makes the first call to the agency. A referral from the discharge team that includes mobility, cognition, and equipment status answers those questions directly.
Name what remains after discharge
After a safe discharge, recovery at home still needs an owner. A useful referral says plainly what is still open: a follow-up appointment not yet scheduled, a prescription not yet filled, a question the family has not answered. OPA’s free Discharge Day worksheet and Residual Outcome Worksheet give families and teams a shared format for those items.
The Weakest Link, Book I of the Operational Reliability Series, follows a family through an acute healthcare crisis. The story turns on handoffs where care breaks down between organizations and between the official plan and the family. Read about the book.
Weekend and late-day discharges
A Friday afternoon discharge leaves few business hours to staff a shift and confirm equipment. When a weekend discharge is likely, a referral sent early in the week with a tentative date gives the agency time to plan coverage.
A first step for your team
Compare your current home care referral form with the table above. Add any line your form does not ask for.
To refer a patient to OPA for personal care or skilled nursing at home, see how care starts at OPA.
Payer and authorization rules change. Requirements and services can change. Confirm requirements with the payer, such as the VA, before discharge.
For a reliable next step, use AHRQ discharge-planning resources for the official details, then use how care starts when your family needs to organize support at home.
For a related decision, AHRQ transition-of-care resources can help frame the question, and this site’s Next-of-Kin Box guide offers a practical next step.
