For referral partners
A home health partner your discharge plan can count on
For hospital case managers, discharge planners, social workers and physician practices across North Texas.
How it works
Four steps from referral to first visit
Discharge planners in published research say they value agencies that respond quickly, see patients soon after discharge and keep them out of the hospital. Our process is built around exactly that.
Send the referral
Call, fax or request a callback. We answer the referring case manager, physician office or family directly.
Accept or decline, fast
Our intake team reviews orders, records and coverage and tells you plainly whether we can accept.
Start of care on the clock
A registered nurse visits on the ordered date, or within 48 hours of referral or discharge, as federal rules require.
Updates that close the loop
You get start-of-care confirmation, a named coordinator and prompt word when a patient's condition changes.
Planner priorities from a survey of hospital discharge planners (PubMed Central). Start-of-care timing from 42 CFR 484.55.
Accountability
The measures we report against
Your preferred-provider list likely weighs the same CMS measures. We manage to them from day one.
Timely initiation of care
Care begins on the physician-ordered date, or within 2 days of referral or hospital discharge.
Discharge Function Score
Patients at or above their expected ability to care for themselves and move around at discharge.
Acute care hospitalization
How often patients are admitted to the hospital during the first 60 days of home health.
Emergency department use without hospitalization
How often patients need the emergency room during the first 60 days.
Discharge to community
Patients who remain home, without unplanned hospital stays, in the 31 days after discharge.
Medication list transferred at discharge
Whether patients and their next provider receive a current, reconciled medication list.
See measure definitions from CMS. OceanCare's own scores will be linked from Care Compare once published.
For physicians
Your orders, carried out precisely
We work under your plan of care and communicate the way busy practices prefer.
Prompt plan of care
Plans of care and orders are sent for signature without delay.
Meaningful updates
We call the physician and your team when a patient’s condition changes, then document what was done.
Same-day escalation
Concerns reach you quickly through your preferred contact method.
Measurable goals
Functional goals written so progress is visible at a glance.
Request a referral callback
Start a referral
Share your contact details and the type of care needed. Our intake team will call you back to receive orders and clinical records through a secure channel.
- Intake phone(314) 703-8622
- Referral fax(214) 614-7479
- What to have readyOrders, face-to-face documentation, recent H&P or discharge summary, medication list and insurance details.
Please do not include patient names, dates of birth or health details. This form is for your contact information only. We collect protected health information through secure channels after we reach you.
Referral questions
What referral partners ask
What documents do you need with a referral?
Physician or allowed practitioner orders, face-to-face encounter documentation, a recent history and physical or discharge summary, the current medication list, and insurance details.
How quickly do you start care?
Federal rules require the initial assessment visit within 48 hours of referral or of the patient's return home, or on the date the physician orders. We schedule every start of care to meet that standard and confirm the date with you.
Can the patient choose OceanCare?
Yes. Medicare patients have the right to choose their home health agency. Patients and families can ask their case manager to send the referral to OceanCare.