Same-day placement.
Lower readmission risk.

A discharge planner or case manager at Houston Methodist, Memorial Hermann, MD Anderson, or Baylor St. Luke’s is coordinating dozens of transitions a week. What actually matters when you refer a patient to a home care agency is not the marketing brochure. It is whether the agency picks up the phone at 4 p.m. on a Friday, whether they can staff by Monday morning, whether the caregiver walks in with the right context, and whether the patient does not come back to your unit within thirty days.

Our intake pattern is built for that specific reality. A call to the direct line during business hours is answered by Andrew Harris, RN, our Clinical Director and former Neuro ICU nurse at Houston Methodist, or by Serhat, our owner-operator. Outside business hours a call to the same number rolls to an on-call clinical lead who can authorise a next-morning start. We collect the patient’s primary diagnosis, the reason for admission, the anticipated discharge date and destination, the anticipated skilled-service overlay (home health, DME, infusion), the family’s decision-maker, and any payer information (LTCI, VA, workers’ comp, private pay). Within two hours we send you a written care proposal you can hand to the family.

The coordination points that matter most in the first 72 hours are the ones discharge planners already know are fragile. Medication reconciliation, the moment where a fresh discharge summary lists twelve medications and the home pill bottles list nine. Weight-bearing or activity restrictions, the moment where a post-op patient tries to shower unassisted. The first outpatient follow-up appointment, the one that gets missed when nobody in the household is well enough to drive. Our caregiver is present for all of those transitions and documents each of them in a format your team can read at a glance.

What our RN-led model brings to the partnership is not just a caregiver but a clinical bridge. Andrew personally reviews every post-hospital care plan for the first week. When our caregiver observes a change in condition, a new productive cough, unexpected weight gain, wound drainage, confusion that was not present at discharge, the escalation runs through Andrew and to the appropriate physician or clinic within hours, not on the next scheduled visit. This is the mechanism that meaningfully reduces the 30-day readmission rate for the patients you send us, and it is the reason your peers refer here.

Practically, partnership works best when your team knows they can call us with a case where the family is unsure, the payer is unclear, or the caregiver need is unusual, and get a real clinical response the same day. We do not run a call centre. We do not read from a script. When a case falls outside our capacity or geography, we say so and refer to a colleague agency we trust. Discharge planners tell us the reason they come back is the consistency of that response, week after week, patient after patient.