TL;DR: Discharge planners evaluate providers on response time, digital presence, quality scores, geographic coverage, and verified contact information — not just relationships. With CMS now requiring hospitals to share quality data during discharge planning, agencies that lack an accessible online presence are losing referrals to providers who make the planner's job easier. This article breaks down the actual criteria, backed by federal requirements and industry data.

Why This Article Exists
Who Discharge Planners Are (and What Pressures They Face)
The Federal Framework: What CMS Requires
The Six Factors That Actually Drive Referral Decisions
Factor 1: Response Time
Factor 2: Verified, Accessible Contact Information
Factor 3: Quality Data and Star Ratings
Factor 4: Service Area and Availability
Factor 5: Digital Presence and Findability
Factor 6: Specialty Capabilities
What Discharge Planners See When They Search for You
How Referral Patterns Are Shifting
What This Means for Your Agency
Frequently Asked Questions

Why This Article Exists {#why-this-article-exists}

Most hospice and home health operators assume referrals come down to relationships. You visit the hospital, you bring lunch, you know the case manager by name. And for decades, that was largely true.

It is no longer the full picture.

Federal regulations have fundamentally changed how hospital discharge planners are required to select and present post-acute care options to patients and families. CMS has mandated that hospitals share quality data, present multiple provider options, and respect patient choice — and the systems discharge planners use to do this increasingly rely on digital information that many independent agencies have never thought to optimize.

This article explains what discharge planners actually evaluate when building a referral list in 2026, why your agency may not be making that list even if you have a great clinical reputation, and what you can do about it.

Who Discharge Planners Are (and What Pressures They Face) {#who-discharge-planners-are}

Discharge planners — also called care transition coordinators, case managers, or utilization review nurses — are typically registered nurses or licensed clinical social workers employed by hospitals. Their job is to ensure patients transition safely from the hospital to the appropriate next level of care.

According to the National Post-acute and Long-term Care Study (NPALS) conducted by the CDC, post-acute care providers serve patients across a wide spectrum of needs, and the discharge planner's role is to match each patient to the right provider in the right setting at the right time.

Here is the reality of that job in 2026:

They are under extreme time pressure. Average hospital lengths of stay continue to decline. CMS tracks readmission rates, and hospitals face financial penalties when patients bounce back within 30 days. Discharge planners often have hours — not days — to identify, contact, and confirm a post-acute provider. The average time from referral to admission for high-performing hospice agencies is approximately 3.5 hours, according to Hospice Advisors' intake benchmarks.

They manage high caseloads. A single discharge planner may manage 15 to 25 active cases simultaneously, each requiring coordination with insurance, family members, and multiple potential providers. They do not have time to track down your fax number, verify your service area, or figure out whether you accept their patient's insurance.

They are legally required to present options. Under 42 CFR § 482.43, hospitals must provide patients with a list of Medicare-participating providers in their area, including quality data. The discharge planner cannot simply refer to the agency they know best — they must present a list, and the patient or family makes the choice.

They increasingly use digital tools. Hospital referral platforms (like Enhabit's referral portal, WellSky CarePort, and others), internal databases, and online directories are standard tools in most discharge planning workflows. If your agency is not in these systems with accurate, current information, you are invisible.

The Federal Framework: What CMS Requires {#the-federal-framework}

Understanding what CMS requires of hospitals during discharge planning explains why digital presence now matters as much as personal relationships.

The discharge planning Conditions of Participation (CoPs), codified in 42 CFR § 482.43 and revised through the September 2019 Final Rule, require hospitals to:

Present quality and resource use data. Hospitals must share data on quality measures and resource use measures for home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs). This includes CMS Star Ratings, quality measure scores, and other publicly available performance data.

Provide a list of available providers. The hospital must provide a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient, that participate in the Medicare program, and that serve the geographic area where the patient resides. The list must include quality data for each provider.

Respect patient choice. The hospital must document that the patient was informed of their freedom to choose among participating providers and that the patient's or family's choice was honored.

Include the patient as an active partner. The discharge planning process must include the patient and their caregivers as active partners, focusing on the patient's goals and treatment preferences.

Transfer necessary medical information. Effective July 1, 2025, hospitals must have written policies and procedures for transferring patients to the appropriate level of care, including all necessary medical information, per CMS guidance QSO-23-16.

What this means in practice: the discharge planner builds a list of eligible providers, attaches quality data, and presents it to the family. The providers on that list are determined by data availability, geographic coverage, quality scores, and accessibility — not solely by who brought bagels to the nursing station last Tuesday.

The Six Factors That Actually Drive Referral Decisions {#the-six-factors}

Based on CMS requirements, industry benchmarking data, and published research on discharge planning workflows, here are the six factors that determine whether your agency makes the referral list.

Factor 1: Response Time {#factor-1-response-time}

This is the single most controllable factor in referral conversion, and it is the one most agencies underperform on.

Industry benchmarks from Hospice Advisors set the standard clearly:

| Metric | Industry Standard | Gold Standard | |--------|------------------|---------------| | Referral-to-admission conversion rate (90-day rolling) | 75–80% | 85%+ | | Same-day admissions (% of total) | 60–70% | 80%+ | | Average time from referral to completed admission | 6–8 hours | 3.5 hours | | Time to first response after referral received | Within 1 hour | Within 30 minutes |

When a discharge planner submits a referral, they are often working with a list of two to four agencies. The first agency to respond with a clear, confident answer — "Yes, we serve that ZIP code, we can admit today, here is who will be there" — typically gets the admission. Agencies that respond slowly, ask the planner to call back, or require multiple follow-ups lose the referral to whichever competitor answered first.

Slow intake response time is consistently cited as one of the top reasons agencies lose referrals they should have won. The discharge planner's job is to move the patient out of an acute bed. Every hour of delay creates risk — for the patient, for the hospital's readmission metrics, and for the planner's caseload.

Factor 2: Verified, Accessible Contact Information {#factor-2-contact-information}

This sounds basic, and it is. It is also where a surprising number of agencies fail.

Discharge planners need to reach your admissions team immediately. If your phone number is wrong on Medicare.gov, if your website lists a general office number that goes to voicemail after 4 PM, or if your Google Business Profile shows hours that do not match reality, the planner moves to the next agency.

A 2023 study published in PMC found that hospital discharge planners frequently cited the need for more accessible, reliable information when referring patients to home health care. The study, which examined discharge planning workflows during and after the COVID-19 pandemic, found that planners struggled with outdated contact information, unclear service area boundaries, and inconsistent availability data.

What discharge planners need to find immediately:

A direct phone number for admissions or intake (not a general office line)
Confirmation of your service area (by ZIP code, county, or city)
Whether you are currently accepting new patients
Your hours of availability for initial assessments
Your fax number or referral portal access (many hospitals still fax referrals)

Every one of these data points should be accurate on your website, your Google Business Profile, your Medicare.gov listing, and any directory where your agency appears — including NDPAP.

Factor 3: Quality Data and Star Ratings {#factor-3-quality-data}

CMS requires hospitals to share quality data with patients during the discharge planning process. This means your quality scores are not just a regulatory checkbox — they are part of the presentation that determines whether a family chooses your agency.

For home health agencies, CMS publishes Quality of Patient Care Star Ratings on Medicare.gov Care Compare, based on measures including:

Timely initiation of care
Improvement in ambulation
Improvement in bed transferring
Improvement in bathing
Improvement in shortness of breath
Acute care hospitalization rates
Emergency department use

For hospice agencies, CMS currently publishes data from the Hospice Quality Reporting Program (HQRP), including measures from the CAHPS Hospice Survey (patient and caregiver experience) and the Hospice Item Set (HIS) quality measures. Notably, CMS is developing a new publicly available hospice scoring system based on potential inappropriate utilization, quality of care, and compliance concerns — proposed for implementation in FY 2027.

According to industry analysis from Hospice News, the types of quality data that most influence referral decisions include:

Live discharge rates — a high rate of live discharges may signal enrollment of inappropriate patients
Visit frequency and timeliness — how quickly the first visit occurs after admission
Patient and caregiver experience scores (CAHPS)
Length of stay distribution — both very short and very long stays raise flags
Levels of care utilization — appropriate use of continuous care, inpatient, and respite

Research published by Axxess confirms that referring providers, particularly hospitals, increasingly examine these quality measures when selecting hospice partners. Agencies with higher quality scores and transparent outcomes data receive more referrals and convert at higher rates.

The practical implication: if a discharge planner pulls up your agency on Care Compare and sees low scores — or worse, no scores because your agency has not been reporting quality data — you will not make the short list presented to the family.

Factor 4: Service Area and Availability {#factor-4-service-area}

Discharge planners need to confirm that your agency serves the patient's home address before they can include you on the referral list. This is a binary filter: either you serve the ZIP code or you do not.

The challenge for many agencies is that their service area information is inconsistent across platforms. Your state license may authorize a broad geographic area, but your actual service delivery may be concentrated in a smaller region. If your Medicare.gov listing says you serve a 50-mile radius but you routinely decline referrals outside a 20-mile range, discharge planners learn not to trust your listed coverage.

Best practice: publish your actual, reliable service area — the geography where you can consistently deliver a same-day or next-day admission — on every platform where your agency appears. Discharge planners respect honesty more than ambition. An agency that reliably serves 15 ZIP codes is more valuable than one that claims 50 but cannot staff the outer ring.

Current availability also matters. Many agencies periodically reach capacity and cannot accept new referrals. If your NDPAP, Google Business Profile, or website listing does not reflect real-time availability, a planner who calls and gets told "we are not accepting patients in that area right now" will remove you from their mental shortlist for future referrals.

Factor 5: Digital Presence and Findability {#factor-5-digital-presence}

Here is where many independent agencies lose without realizing it.

Discharge planners do not operate in a vacuum. When they are building a referral list — particularly for a service area they do not work with frequently — they search. They search Google, they search Medicare.gov, they search internal hospital databases, and they search provider directories.

If your agency does not appear in those searches, you will not be on the list.

A 2023 PMC study on discharge planning information needs found that discharge planners increasingly rely on digital tools and online resources to identify post-acute providers, particularly when working with patients whose home addresses fall outside the planner's usual referral network.

What discharge planners search for:

"[City] hospice care" or "[City] home health agency"
Agency name (to verify contact information and hours)
Medicare.gov Care Compare (for quality data and service area verification)
Internal referral management systems (WellSky CarePort, Enhabit, Forcura, etc.)
Online directories and provider finders

What they evaluate when they land on your listing or website:

Can I find the intake phone number in under 10 seconds?
Does the service area cover my patient's address?
Are they accepting new patients?
Do they have any quality data or accreditation visible?
Does this look like a legitimate, active agency?

An agency with a clean, current Google Business Profile, an accurate Care Compare listing, a verified NDPAP directory page, and a website with a prominent intake phone number will make the shortlist. An agency with a GoDaddy parked page, a disconnected phone number on Google, and no Care Compare data will not — regardless of how good their clinical care actually is.

Factor 6: Specialty Capabilities {#factor-6-specialty-capabilities}

For certain patient populations, discharge planners need providers with specific capabilities that go beyond general hospice or home health services:

Pediatric hospice or home health — very few agencies serve this population
IV therapy and infusion services — required for certain home health patients
Ventilator or tracheostomy care — specialty respiratory services
Non-English language capabilities — in diverse metro areas, language match is critical
Wound care specialty — for complex post-surgical patients
Behavioral health integration — for patients with co-occurring psychiatric conditions
Extended hours or 24/7 intake — for discharges that occur on evenings and weekends

Agencies that clearly communicate their specialty capabilities — on their website, in their directory listings, and on their Google Business Profile — receive referrals for these patients specifically because planners know where to send them.

If your agency provides continuous care hospice, has bilingual staff, or offers wound care specialization, and none of that information appears anywhere online, you are leaving referrals on the table.

What Discharge Planners See When They Search for You {#what-they-see}

To understand how your agency appears to a discharge planner, try this exercise: open an incognito browser window and search for your agency by name. Then search for "[your city] hospice care" or "[your city] home health agency."

Ask yourself:

Does your agency appear in the first page of results?
Is the phone number that shows up in Google actually your intake line?
Does your Google Business Profile exist? Is it claimed and verified?
If you click through to your website, can you find the intake number within 5 seconds?
Does your Care Compare listing on Medicare.gov show current quality data?
When you search your agency on NDPAP.org, is the listing claimed and verified with accurate contact information?

If the answer to any of these is "no," discharge planners are experiencing the same friction — and they are choosing the agency where the answer is "yes."

How Referral Patterns Are Shifting {#how-referral-patterns-are-shifting}

The hospice industry is growing. According to the 2025 NHPCO Facts and Figures Executive Summary, 1.91 million Medicare beneficiaries enrolled in hospice care in 2024, a 4.4% increase from 2023. For the first time, 53.1% of all Medicare decedents received hospice care — the highest utilization rate ever recorded.

But while the overall pie is growing, the way referrals reach agencies is changing:

Hospital referrals remain dominant but are becoming more structured. CMS discharge planning requirements mean that hospital referrals now come through formal channels with quality data attached, rather than informal phone calls from a case manager who knows your name.

Family-initiated inquiries are increasing. As families research care options online before and during hospital stays, more patients arrive at the discharge planning conversation with a provider preference already formed. Agencies with strong digital presence capture these preferences before the discharge planner is even involved.

Referral platform adoption is accelerating. More hospitals use electronic referral management systems that automatically populate provider options based on service area, quality data, and availability. If your agency is not in these systems — or if your data in these systems is outdated — you are excluded from the automated shortlist.

CMS oversight is increasing scrutiny on referral patterns. The April 2025 CMS Hospice Monitoring Report tracks referral patterns, live discharge rates, and other utilization metrics. Agencies with unusual referral concentration (too many referrals from a single source) face increased scrutiny for potential Anti-Kickback Statute violations.

The March 2026 MedPAC Report to Congress noted significant variation in post-acute care referral patterns across markets, driven by differences in provider supply, referral practices, and patient preferences — reinforcing that agencies that make themselves easy to find and evaluate will capture disproportionate market share in fragmented markets.

What This Means for Your Agency {#what-this-means}

The discharge planner's evaluation criteria have shifted from "who do I know?" to "who can I verify, present to the family with data, and reach immediately?" That shift rewards agencies that invest in three things:

1. Intake infrastructure. Respond to referrals within 30 minutes. Staff your intake line during extended hours, including weekends. Track your referral-to-admission conversion rate monthly — the gold standard is 85% at 90 days.

2. Data accuracy across every platform. Audit your listing on Medicare.gov, Google Business Profile, NDPAP, and your own website quarterly. Ensure your intake phone number, service area, hours, and availability status are identical everywhere. A single wrong phone number can cost you dozens of referrals before anyone tells you about it.

3. Digital findability. When a discharge planner searches "[your city] hospice care," your agency should appear. This means having a claimed and optimized Google Business Profile, an accurate directory presence, and a website that loads quickly and puts your intake number front and center.

None of these require a marketing budget. They require attention, accuracy, and consistency — the same operational discipline you apply to clinical care.

Frequently Asked Questions {#faq}

Do discharge planners still rely on personal relationships for referrals?

Relationships still matter, but they are no longer sufficient. CMS requires hospitals to present multiple provider options with quality data, which means even a planner who personally prefers your agency must include other options on the list. The family ultimately chooses — and families increasingly research providers online before making that choice.

How do I find out if my agency's information is accurate on Medicare.gov?

Visit Medicare.gov Care Compare and search for your agency by name or location. Review your listed address, phone number, services, and quality data. If anything is incorrect, contact your Medicare Administrative Contractor (MAC) to update your enrollment information through PECOS.

What is the most important factor in getting more referrals?

Response time. Data consistently shows that the first agency to respond to a referral inquiry with a definitive answer wins the admission. Investing in intake staffing and response protocols will produce faster results than any other single change.

How many referral sources should my agency have?

Diversification protects your business. If more than 50% of your referrals come from a single source, you face both business risk (if that source changes preferred providers) and regulatory risk (concentrated referral patterns can trigger Anti-Kickback Statute scrutiny from CMS). Aim for no single source representing more than 25–30% of total referrals.

Does having a directory listing on NDPAP help with discharge planner referrals?

Yes. Discharge planners use multiple tools to identify providers in a patient's service area, including online directories. A verified, complete listing on NDPAP with accurate contact information, service area, and availability status makes your agency discoverable to planners who are searching for providers outside their usual network. Unlike lead-generation directories, NDPAP provides direct contact information — the planner calls you directly, with no intermediary.

This article is part of NDPAP's provider resource series. NDPAP is the National Directory of Post-Acute Providers — a free directory helping families, discharge planners, and case managers find hospice, home health, DME, and pharmacy providers across all 50 states. Claim your listing →

Sources cited in this article:

what are discharge planners looking for when they send referrals

Referral to Admission Process](https://hospiceadvisors.com/the-anatomy-of-a-high-performing-referral-inquiry-to-admission-process/)

Hospice News: 5 Top Types of Quality Data Hospices Should Be Watching

What Discharge Planners Actually Evaluate Before Referring in 2026

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