Referral progress should be visible before someone has to ask.
Our Hearts is designing one shared pathway for early fit direction, explicit ownership, first-shift confirmation, and post-placement communication.
AcknowledgeOwn the next actionConfirm the handoff
A human handoff
Shared status should strengthen direct communication.
The workflow makes ownership and next action visible, while the people involved remain responsible for the conversation and the handoff.
Hospitals
Move from discharge question to a visible home-care next action.
State agencies
Clarify scope, readiness, ownership, and the information still required.
Care agencies
Explore complementary support, capacity questions, and coordinated placement.
Fewer silent handoffs.
Each stage has a status, an owner, and a next action. The model does not claim contracts, payer participation, clinical outcomes, or guaranteed capacity.
- 1Referral received
- 2Acknowledged
- 3Scope review
- 4Availability direction
- 5Consultation scheduled
- 6Care plan prepared
- 7Care team matching
- 8Placement confirmed