From the first referral to the signed plan of care, agencies must ensure a smooth transition into care while meeting strict compliance requirements and quality standards.
This overview explains client intake, the Start of Care (SOC) visit, and the OASIS assessment process, highlighting typical workflows and best practices drawn from our internal Skilled Care meetings and official CMS guidance. It’s intended for non-clinical staff (product, support, sales, training) to understand what happens behind the scenes when a new patient enters a home health agency’s care.
Client Intake in Skilled Home Health
Referral and Intake: The process usually begins with a referral. Common referral sources include hospital discharge planners or case managers, who refer patients needing continued care at home, as well as physicians’ offices (primary care doctors or specialists), skilled nursing or rehab facilities, or even families and patients directly contacting the agency. For example, an agency in one of our internal meetings described how sometimes families call seeking help for a loved one, which prompts the agency to reach out to the patient’s doctor to obtain an order to evaluate and treat. In other cases, a hospital or physician provides a formal referral that includes the patient’s information, diagnoses, recent visit notes, and an initial order for home health services (often accompanied by documentation of that required face-to-face encounter).
Inquiries vs. Referrals: Some agencies differentiate between an inquiry (when someone asks about services but no physician order or formal referral is present yet) and an official referral (which starts the clock on regulatory timeframes). Inquiry is a preliminary info gathering stage; by itself, it “does not start your time” for compliance deadlines. Once it becomes a formal referral – meaning the agency has sufficient patient info and a doctor’s authorization to proceed – then the agency must act promptly. Best practice is to schedule and complete the SOC visit within 48 hours of receiving a referral from a hospital discharge or doctor (unless the physician specifies a later date). This is measured in Medicare’s Timely Initiation of Care quality metric. In practice, some state programs or agencies allow up to 72 hours to accept or refuse a referral and initiate care. Either way, speed is critical for patient care and compliance – if an agency cannot meet the timeline or lacks capacity (staffing, etc.), they may have to decline the referral.
Screening & Eligibility: During intake, the agency conducts an initial screening to confirm that the patient meets home health eligibility and that the agency can safely and legally provide the needed services. Key criteria include:
Skilled need: Is there a need for skilled nursing or therapy services? Home health is designed for patients requiring clinical interventions (e.g., wound care, IV therapy, physical therapy) rather than just custodial care. If the patient only needs personal support without medical care, they might be referred to a non-medical home care or community service instead.
Homebound status: Medicare requires that the patient is homebound, meaning it’s very difficult for them to leave home, and they only do so infrequently or for essential purposes (like medical visits). The intake team will often ask about the patient’s mobility and living situation to gauge if they meet this standard.
Payer source: The agency verifies insurance or payer eligibility. If the patient is under Medicare, the intake staff may use an eligibility portal to confirm Medicare coverage and any managed care arrangements. For Medicaid or other state programs, the agency might check state systems for prior authorization requirements. For private insurance, they may need to pre-certify home health services with the insurer. If the patient is uninsured or ineligible, the agency will discuss private-pay options or other resources.
Service needs & capacity: The intake coordinator will gather details on what specific services are needed (nursing visits, physical therapy, etc.) and the patient’s location, then ensure the agency has appropriate staff and coverage in that area. One agency described using an intake “quick checklist” to decide whether to accept a case, asking things like “Do we have a nurse available in that area? Do we have the right clinician (e.g., wound care nurse or IV-certified nurse) and can we meet the required start date?”. Only if these questions can be answered “yes” does the agency formally accept the referral.
If the patient is not a fit (for example, they don’t meet eligibility, require services the agency can’t provide, or are outside the service area), the agency must document a timely refusal, often within the same 48–72 hour window, and notify the referral source so alternate arrangements can be made.
Physician Orders at Intake: Home health must operate under physician orders. So, a critical part of intake is ensuring there is a valid doctor’s order to start home health. Ideally, the referral comes with a written order from the physician (for example, “Evaluate and treat for home health (SN, PT) due to patient’s recent hip surgery”). In Medicare terms, this initial order (along with the face-to-face encounter documentation) is part of the physician’s certification of home health services.
However, verbal orders often play a role at intake too. For instance, one of our nurses explained that even if a written referral was received, they “like to call and talk to the doctor’s office and say, ‘We’re about to start care; I just need a verbal order that you’re OK with that,’” before sending the nurse out for the SOC visit. This verbal order to “evaluate and treat” gives the clinician immediate authorization to assess the patient and begin care pending the formal paperwork. Verbal orders must later be documented and signed by the physician (often after the SOC visit, when the full plan of care is prepared).
If a patient self-refers or a family calls without a doctor’s order, the agency will contact the patient’s physician to obtain that initial authorization (again, typically a verbal order to initiate care). As a nurse described, “Say they called and said, ‘my mom has dementia and I’m having trouble managing her medications.’ I would reach out to the doctor and say, ‘I don’t have an order for this, but here’s what they’re saying – do you agree, and can I get an order to do an eval and treat?’”. This step ensures physician involvement from the start, as required.
Primary vs. Secondary Physicians: Often the patient’s Primary Care Physician (PCP) or attending physician will be the one to sign and oversee the home health plan of care. If the referral comes from a hospitalist or specialist who won’t be following the patient long-term, the agency coordinates with the PCP or appropriate doctor to assume responsibility for home health orders. In some cases, multiple physicians might be involved in a patient’s care (e.g., a surgeon, a cardiologist, and a PCP). Home health must designate one as the primary physician for the home health episode – this is the doctor who approves and signs the overall plan of care and any general orders. Other physicians can still give “secondary” or consult orders for their specialty (for example, a urologist might order a catheter change regimen), but those typically are incorporated via coordination with the primary physician or as separate orders that the primary must acknowledge in the plan of care. The primary doctor remains the one who signs the plan of care (CMS-485) and is considered the certifying physician for that home health episode.
Insurance Authorizations: For Medicare patients, intake is mostly about verifying eligibility and documenting the face-to-face encounter; Medicare typically does not require pre-authorization for standard home health episodes. For Medicaid managed care or private insurance, the intake team may need to obtain prior authorization for visits or services. This can include submitting an insurance-specific intake form or electronic request right after the referral, with details on the patient and planned care. In one discussion, an intake manager mentioned using a state portal or e-authorization system during intake to confirm eligibility and request initial approval for visits.
Outcome of Intake: By the end of the intake phase, the agency should have:
Patient information recorded in their system.
A preliminary understanding of the patient’s needs and eligibility.
Initial physician orders (verbal or written) to start the care.
A scheduled date/time for the Start of Care visit, assigned to a clinician qualified for the case.
Face-to-face documentation (or a plan to obtain it) and any other required documents from referral sources (e.g., recent history & physical, hospital discharge summary, advanced directives if available). One challenge agencies note is that referrals often omit things like advanced directives (DNR orders) or power of attorney papers – which then requires follow-up with hospitals or families to gather those documents so the patient’s wishes are clear.
At this point, the agency has “accepted” the patient, and the SOC visit will formally start the care. The next sections describe what happens during and after that Start of Care.
The Start of Care (SOC) Visit: Kicking Off Home Health Services
Definition of SOC: In home health, the Start of Care (SOC) is the initial admission visit where the patient is formally assessed and admitted to home health services. The date of this visit becomes Day 1 of the home health episode, and it’s a key regulatory milestone that triggers requirements like OASIS data collection and Medicare’s billing cycle. The SOC is typically performed by a Registered Nurse (RN) if nursing is ordered, or by a physical therapist (PT) if rehab therapy is the only service needed. (An exception: if only PT, OT, or SLP services are ordered, a PT, occupational therapist, or speech therapist can initiate care in place of the nurse.)
Timing: As noted, best practice and CMS quality standards call for the SOC visit to be done within 2 days of the referral or hospital discharge (whichever is later), unless the physician’s order specifies a different start date. If an agency can’t meet this, they may hand off the referral to another provider. If a delay is unavoidable (for instance, patient isn’t available until a later date), the physician should explicitly state the later SOC date so that it’s compliant with CMS’s rules (this can be documented in the order).
What happens during the SOC visit? The SOC visit is usually longer than a typical visit (often 1.5–2 hours) because it involves a comprehensive assessment and a lot of documentation. The admitting clinician will:
Review and confirm the referral information. This often includes discussing the reason for home health, verifying the primary diagnosis and any recent hospital or physician interventions, and ensuring any immediate needs (e.g., new prescriptions, equipment) are addressed.
Establish consent and patient rights. The clinician will explain the home health services, obtain any consents or admissions paperwork, and provide information on patient rights and responsibilities. (This is part of CMS’s Conditions of Participation.)
Perform a head-to-toe assessment of the patient’s clinical status. Vital signs are taken; pain levels and symptoms are reviewed; physical, cognitive, and psychosocial status is assessed. All body systems are examined as relevant (neurological, cardiac, respiratory, skin, etc.) to create a baseline.
Assess functional status and home safety. The clinician evaluates how well the patient manages activities of daily living (ADLs) and mobility, identifies any safety hazards in the home (like fall risks), and determines what kind of help the patient has or needs (caregiver support, equipment, etc.).
Medication reconciliation: The clinician reviews all medications the patient is taking, often by physically going through pill bottles with the patient. They check for any potential issues like drug interactions, duplications, or medications that need clarification, and ensure the medication list is up-to-date. This is critical, as medication discrepancies are a major cause of hospital readmissions.
Identify the patient’s goals and needs. Together with the patient (and family, if applicable), the clinician discusses care goals – for example, improving mobility, managing wound care, educating the patient on a new diagnosis – and begins forming a plan of care for the upcoming weeks.
Provide initial skilled interventions as needed. If the patient has an immediate need (like a wound dressing change or teaching on a new medication), the nurse or therapist will address it during this first visit as per the “evaluate and treat” order. They will also educate the patient or caregiver from day one on important safety or care tasks.
The SOC visit is essentially a detailed information-gathering and care-planning session. By the end of it, the clinician has completed a Comprehensive Assessment of the patient’s condition and has started filling out the OASIS data set (more on OASIS below). They will also generate an initial Plan of Care based on the findings.
Documenting the SOC: The clinician typically documents this visit in an electronic health record system, completing all required assessment fields and OASIS items. Importantly, CMS mandates that the comprehensive assessment be completed (and documented) within 5 days after the SOC date – but many agencies aim to finalize it sooner so that care planning and physician orders can be promptly confirmed.
Because the SOC assessment is extensive, agencies might break up the documentation. One approach is to have the clinician complete the most crucial parts (the “No Pay RAP” or Notice of Admission is no longer required as of 2022 for Medicare, but timely submission of a Notice of Admission within 5 days of SOC is still required for Medicare billing compliance – outside scope) in the home or immediately afterward, then finalize remaining sections (like detailed OASIS responses) later that day. Internal processes may also include a clinical review or QA check of the SOC documents by a supervisor or Quality Assurance nurse before they are considered final, in order to catch any documentation issues that could lead to claim denials (given that 51% of home health Medicare payment denials are due to insufficient documentation).
Homebound and Eligibility Confirmation: The SOC clinician will double-check Medicare eligibility criteria during the visit. The RN is responsible for confirming that the patient is indeed homebound and needs intermittent skilled care, and will document the specific reasons (for example, “Patient requires use of a walker and assistance to leave home, and leaving home is medically contraindicated due to shortness of breath”). This is critical for Medicare compliance – both at SOC and at every recert, eligibility must be reconfirmed. If any eligibility concern arises, the clinician will alert their office or the referring physician (for instance, if the patient was found to not actually be homebound, the agency might not proceed with admission).
OASIS: The Standardized Assessment at Start of Care
A cornerstone of the SOC process in Medicare-certified home health is OASIS. OASIS stands for Outcome and Assessment Information Set – it’s a standardized data set of about 100+ items that CMS requires agencies to collect at specific points (SOC, Resumption of Care, Recertification, Transfer, Discharge) for each patient.
Purpose of OASIS: OASIS serves multiple purposes:
It ensures the comprehensive assessment covers all important domains (clinical, functional, psychosocial, etc.) in a standardized way.
The data is used by CMS for quality monitoring (impacting star ratings and value-based programs), for outcome measurement (tracking patient improvement or decline), and for payment calculation under Medicare’s PDGM (Patient-Driven Groupings Model) if Medicare is payer.
It provides a consistent way to report patient status across all agencies nationally, which aids in research and policy decisions.
At SOC, the clinician incorporates OASIS into their assessment. In fact, CMS requires that the SOC comprehensive assessment “incorporate the current version of the OASIS items” – it’s baked into the assessment standard. Most agencies use software that integrates OASIS questions into the nurse’s SOC documentation workflow so the nurse doesn’t fill out a separate form on paper (in past years, nurses used a lengthy paper OASIS form known as OASIS-E).
Examples of OASIS items: OASIS covers a broad range, including:
Clinical items (diagnoses, vision, pain levels, wounds).
Functional status (ability to dress, bathe, walk, transfer).
Neuro/behavioral status (cognitive function, anxiety, depression).
Continence, injections, emergent care use, etc.
A standardized scoring of patients’ risk and health status. For example, OASIS asks if the patient is at risk of hospitalization, or if they have had recent falls, etc.
Completing and Submitting OASIS: After the SOC visit, the clinician ensures all OASIS responses are answered. Agencies often have a process where a clinical manager reviews the OASIS responses for accuracy and consistency (this internal QA “scrubbing” was mentioned in our meetings as being done by the Director of Nursing to reduce errors). Once finalized, the OASIS data must be electronically transmitted to CMS. According to CMS regulations, each completed OASIS assessment must be encoded and transmitted within 30 days of completion. In practice, many agencies aim to submit much sooner (e.g., within a week or two of SOC) since the OASIS data drives Medicare’s payment grouping and because any submission errors need timely correction.
CMS’s internet-based system for OASIS submissions is called iQIES (Internet Quality Improvement and Evaluation System). Agencies upload the OASIS data and receive feedback on whether it was accepted or rejected for any errors. If an OASIS submission is rejected (due to data format issues or inconsistencies), it must be corrected and resubmitted promptly to remain compliant and avoid payment delays.
OASIS vs. Plan of Care: One important point for non-clinical folks: the OASIS assessment is not the same as the physician’s plan of care (POC), and OASIS itself is not typically sent to the physician. OASIS data is internal (sent to CMS) and is a research/quality dataset. By contrast, the plan of care – often still called by its historical form number “CMS-485” – is the doctor’s orders and care plan that the physician signs. However, both are created from the same SOC assessment:
The clinician completes the full SOC assessment, answering OASIS items plus additional agency-specific or regulatory-required assessments (for example, sections on caregiver availability, home environment, immunization status, etc., which are not part of OASIS but are part of a complete assessment).
From that electronic assessment, the system can generate the draft Plan of Care document (CMS-485) by pulling in relevant information such as diagnoses, medications, treatments needed, visit frequency, functional limitations, goals, etc. Our team meetings discussed how the software should ideally auto-populate the plan of care from the OASIS assessment to avoid duplicate data entry. In practice, clinicians sometimes have to edit the auto-generated POC, especially to ensure medication lists and dates are correct.
Quality Check & Sign-off: Before or just after submitting OASIS to CMS, agency procedures call for internal QA: a knowledgeable clinician or manager reviews the OASIS for any inconsistencies or missing justifications (e.g., verifying that homebound reasons are explicitly documented). This is crucial because insufficient or inconsistent OASIS data can lead to claim denials later on if audited. After QA, the OASIS is locked and ready to submit to CMS.
The Plan of Care (CMS-485) and Physician Orders
Parallel to the OASIS submission process, the agency finalizes the Plan of Care (POC) document, often referred to by its legacy form number CMS-485. The POC is essentially the prescription for home health services, detailing what services and treatments will be provided, at what frequency, and what goals are being addressed. It includes:
Demographics and diagnoses: All pertinent diagnoses (primary and secondary) that drive the care.
Medications: A reconciled medication profile.
All orders for care: including specific treatments (wound care instructions, IV therapy protocols, catheter care, etc.), activity and diet orders, safety measures, equipment needed, etc.
Disciplines and visit frequency: e.g., Skilled Nursing 2 visits/week for 4 weeks, Physical Therapy 2x/week for 3 weeks, etc.
Measurable goals and outcomes: what the care aims to achieve (e.g., wound healed, patient independent in medication management, improvement in gait after therapy).
Other interventions: labs, teaching topics, coordination with other providers, etc.
Physician’s Role: The plan of care must be reviewed and signed by the physician (or allowed practitioner) who is overseeing the home health plan. Usually this is the patient’s PCP or the doctor who wrote the initial order. The POC is sent (often via fax or electronic signature system) to the physician shortly after the SOC visit, for review and signature. In our meetings, a nurse described how their system would fax the plan of care automatically and alert when a signed copy was returned. Until the signed POC is returned, the agency operates under the initial verbal orders; once returned, the signed POC becomes the definitive set of orders for the patient’s episode.
It’s worth noting that Medicare’s Conditions of Participation require that the physician sign the POC and any subsequent plan updates (like addendums or recertifications), and that they do so in a timely manner. Agencies must track and follow up on outstanding signatures. Our team uses status tracking (e.g., marking an order “sent to physician” and then “physician signed” when received) so that they can audit that all required signatures are on file. Physicians typically must sign and date the initial plan of care and have the option to add or modify orders. They also certify by signing that the patient meets home health eligibility (homebound, needs intermittent skilled care, etc.) – basically endorsing the initial certification.
Addendums and Order Changes: After the initial POC is in place, things can change. New issues might arise or doctors might alter the treatment approach. When changes occur, they are handled via physician orders, which may be referred to as addendum orders or interim orders if they modify the established POC. For example, if the doctor adds a new medication or changes a wound care protocol two weeks into care, the nurse will:
Obtain a new order (verbally or in writing) from the physician for the change.
Document that order in the system and send it for the physician’s signature (if verbal).
Implement the order and update the relevant parts of the care plan (e.g., update the medication list, change the visit schedule, etc.) – making sure the team is informed.
Keep the signed order as part of the medical record, as it becomes an official addendum to the POC.
These addendum orders do not automatically change the original POC document that the physician signed (that stays as is), but they carry equal weight as physician orders and need to be available for review. A best practice is to ensure any significant changes are also clearly communicated and integrated into the next plan of care update (e.g., at recertification) to provide continuity and avoid duplicate work. In our internal meetings, we identified a workflow gap where changes made via addendum weren’t automatically carrying over into the system’s next OASIS assessment, meaning nurses had to manually re-enter those changes at recertification. In an ideal process, the system or clinician would flag such changes so they are reflected in future care plans, reducing clerical rework and ensuring consistency.
Recertification and Continuing Care: A home health certification period lasts 60 days. Toward the end of that period (typically in the last 5 days of it), a decision is made whether to discharge the patient or recertify for a new period. If the patient still needs ongoing skilled care, a Recertification OASIS assessment is completed (often by a nurse during a visit around day 56–60) and a new plan of care for the next 60 days is formulated for the physician to sign. This recert cycle repeats as long as the patient remains eligible and in need of home health. If at any point the patient’s condition stabilizes to where no further skilled care is needed (or they no longer meet homebound status), the agency will discharge the patient from home health, often with instructions or referral to other resources if needed.
Compliance Considerations: By design, skilled home health operates in a tightly regulated environment:
The initial certification (SOC) and each recertification require physician approval and a corresponding OASIS submission to CMS.
Notice of Admission (NOA): (For Medicare) The agency must file a NOA with Medicare within 5 days of SOC to establish the patient’s episode (though this is more of a billing process, not visible to most clinicians or support staff).
State or Payer-specific rules: Some states or managed care programs may have additional intake rules – e.g., the internal meeting transcript from Indiana referenced a state rule of 72 hours to accept/start care and then 48 hours after the assessment to submit it to the state’s system, under Medicaid managed care. While such specifics vary, the general principle is similar: timeliness and accuracy at SOC are crucial to compliance.
Summary of Key Steps and Documents
Let’s tie together the major elements of the intake-to-SOC process with their purpose and inter-relationships:
Stage/Document | What It Is | Who Completes It | Key Outcomes |
Referral & Intake | Initial patient referral (from hospital, doctor, etc.) and agency’s screening process. May start as an “inquiry” (info gathering) then become a formal referral with a physician’s order. | Intake coordinator or clinical manager; physician provides initial order (verbal or written). | ✔ Accept or decline patient within required timeframe. |
Start of Care Visit (SOC) | First home health visit; RN (or PT/OT/SLP if only therapy) conducts a comprehensive assessment. SOC date triggers episode start. | Admitting clinician (RN or therapist). | ✔ Complete full head-to-toe assessment, incl. environment, support, safety. |
OASIS Assessment (SOC) | The standardized data set integrated into the SOC assessment, required by CMS at SOC. OASIS-E is current version. | Same clinician as SOC visit; often reviewed by QA nurse before submission. | ✔ Collect structured info on clinical, functional status, etc.. |
Plan of Care (CMS-485) | The physician-ordered care plan for the certification period (usually 60 days). Lists all disciplines, visit frequencies, interventions, and goals. | Admitting clinician drafts from assessment; Physician reviews, signs, and may modify. | ✔ Formal doctor’s orders for home health (must be signed). |
Note: While OASIS and the Plan of Care both stem from the SOC assessment, they serve different masters: OASIS is for CMS data submission; the Plan of Care is for physician direction and clinical practice. However, they should mirror each other in content (e.g., patient condition, needs) to maintain consistency.
Best Practices & Takeaways
Ensuring a successful start-of-care in home health involves balancing speed, thoroughness, and compliance. Here are some best-practice principles emphasized by our team and CMS:
Act quickly but don’t rush documentation. Begin care promptly (ideally within 48 hours), but also gather all needed data. An incomplete SOC assessment can cause rework or even jeopardize compliance. For instance, failing to document the patient’s homebound reasons or including an ambiguous care plan can lead to Medicare claim denials. Build time for QA review of the SOC paperwork (OASIS & POC) before finalizing it.
Clear, thorough documentation from day one. The SOC is the foundation for the entire episode. Document the patient’s baseline status and needs clearly. This not only informs the plan of care but also guards against scrutiny in audits. (CMS specifically cites insufficient documentation as the top denial reason, so details matter.) Include supporting info like the face-to-face encounter note and any advanced directives with the referral or in the record so that everything is on file.
Strong physician communication. Early and ongoing communication with the physician is key. At intake, clarify which doctor is the primary for home health, and ensure they’re on board to sign orders. Clarify any ambiguous orders (e.g., if the referral says “nursing eval” but therapy might also be needed). During SOC, if you find new issues (say, a medication discrepancy), call the doctor to reconcile it immediately or get new orders. Timely verbal orders followed by written signatures keep care moving without delay.
Robust intake processes to avoid downstream issues. A lot of later headaches (e.g. billing rejections, missed visits) can be traced to intake missteps. Validate insurance and authorization requirements at intake so you don’t provide services that aren’t covered. Confirm the referral is complete – if something like vital documentation (e.g. face-to-face note) is missing, chase it early. As one of our discussions highlighted, “garbage in, garbage out” – invest time upfront to get accurate data into the system, which makes scheduling, billing, and care smoother later.
Use integrated systems to reduce duplicate work. Ideally, your software should pull data from OASIS to pre-fill the Plan of Care, and carry forward key info to recertifications. This prevents omissions and saves time. Our team identified that when systems don’t carry forward POC addendum changes to the next OASIS, nurses must manually re-enter those changes at recert, increasing workload and risk of errors. Aim to configure systems or processes such that critical updates (like new orders, changed goals) are flagged for inclusion in the next assessment.
Monitor deadlines and follow-up tasks. Once the SOC is done, the clock doesn’t stop. Ensure OASIS is submitted within 30 days (sooner is better) and verify it was accepted. Track that the signed POC comes back from the physician – agencies can’t bill without it. Also, set reminders for recertification near day 60 and any ancillary deadlines (e.g., specific payer forms). One internal tip: using a “dashboard” or tickler system to flag unsigned orders or upcoming recerts can help staff stay ahead of compliance tasks.
By understanding the intake → SOC → OASIS → POC sequence and the rationale behind each piece, non-clinical team members can better support clinicians and patients. For example, support staff might help chase down a missing face-to-face note or ensure a faxed order gets logged correctly – knowing that these pieces are not just paperwork, but pivotal for patient care and legal compliance.
Skilled home health is a complex, federally regulated service – unlike private home care, it involves mandatory assessments (OASIS), physician-directed plans (CMS-485), and strict timing rules. But with solid processes and teamwork at intake and start of care, agencies can set the stage for successful outcomes. The goal is to admit patients efficiently, with all the right boxes checked, so the clinical team can focus on delivering care and helping patients recover.