Home Health Coordination Agent
Matches patients to home health agencies, tracks start-of-care, and escalates delayed post-acute starts.
Home health referrals fail when agency match is slow, capacity is unknown, and start-of-care dates slip without escalation
Delayed SOC leaves high-risk patients without skilled nursing, therapy, or wound care after discharge
Case managers spend hours calling agencies and re-faxing packets
The Home Health Coordination Agent matches patients to agencies, tracks SOC, and escalates delays before harm or readmission risk rises
The Home Health Coordination Agent evaluates post-acute needs, matches patients to home health agencies by service capability, geography, payer, and capacity, and transmits complete referral packets. It monitors acceptance and start-of-care milestones against SLA timers and escalates delayed starts to care management and agency partners. Performance metrics inform preferred-provider networks and discharge planning.
Capture Home Health Needs
- Extract skilled needs, frequency, and clinical complexity from the plan of care
- Confirm payer home health benefits and authorization status
- Record patient address, caregiver support, and preferred agency if any
Match and Refer to Agencies
- Rank agencies by capability, capacity, quality, and network status
- Send referral packets electronically to top matches
- Track accept/decline responses and cascade to alternate agencies
Track Start-of-Care Milestones
- Record agency acceptance, scheduled SOC date, and clinician assignment
- Compare SOC timing against policy windows from discharge
- Confirm first visit completion and initial assessment status
Escalate Delays and Report Performance
- Alert care managers when SOC is at risk or past SLA
- Trigger alternate agency placement when delays persist
- Report agency turnaround, decline reasons, and SOC completion rates