Senior Living and Hospital Referrals: Are You on the Magic List?

Reduce hospital readmissions, lower costs and increase referrals — it’s hard to have a conversation about senior housing nowadays without hearing these phrases.

By addressing hospital readmissions, providers can lower the costs of health care, while, in turn, increasing their referral base and starting the cycle over again. However, many of the discussions regarding referrals center around web-based campaigns or giant lead-gen websites.

And as many in the industry will say, senior living is a people business. That goes for referrals too.


Just ask Jacqueline Bechtold Gordon, who has been a hospital discharge planner for more than 30 years and understands the importance of face time when it comes to generating referrals.

Holding a list of post-hospital care (including senior housing, home health care and home care) in the hospital’s area, Gordon becomes a key influencer, helping patients and their families decide where to go next — like a gatekeeper of referrals.

Her advice to senior housing providers who want to access these referrals? Get on a discharge planner’s good side and your community might just move to the top of that list.


Gordon, who works in the emergency room at Adventist Medical Center-Portland, explains exactly how the discharge process works (and how to push your way up the list) in a Q&A with Sharon Brothers, CEO of the Institute for Professional Care Education (IPCed), during a recent webinar hosted by the institute.

Sharon Brothers: It used to be skilled nursing was the only option for discharge. Well, if it’s the right setting a person could go home with 24-hour home care, or they could go to assisted living and have a skilled nurse from a home health agency visit them. There are more options today, don’t you think?

Jacqueline Bechtold Gordon: There’s lots of options today. And I might mention that in the emergency room, we do all of it. We don’t just do the [senior housing] placements. We do home care, home health care, hospice, because we’re the only ones there to do that, especially in after-hours.

SB: How does the referral process work in the ER?

JBG: The doctor comes to me and says that this patient has a need. It’s not working out at home, either they don’t have enough care in the home and the patient or family would like to increase the care in the home, or they may need to go into a facility of some type.

I take a look at the [patient’s] history and physical. I go in and talk to the person and family, just finding out what has been happening at home, what their needs are and what they want to do. … Money is always a big issue. So I need to know whether they have Medicare or Medicaid. I assess the situation and find out what they want to do and start working on it and coming up with a solution.

SB: You’ve done the assessment phase and know what their financial capabilities are; what’s the next step?

JBG: It depends on what I’m doing. [If] it’s home care, then we would give the family a list of home care agencies and have them choose one that they want to work with. Either they or we will make a call to the agency and see if they’ll provide what the family needs. If it’s home health, we’ll give them a list of home health agencies or ask if they have a home health agency they want to use.

For a nursing facility I give them — depending on their insurance — the list that’s appropriate and ask them to come up with at least three options. In the emergency room, I just want them to come up with one option because it has to be done very quickly. Then I’ll get the information to those places and see which place can take them, and whoever it works out the quickest with is usually the one where that patient goes.

SB: So providers’ responsiveness and speed are really important in the ER. For the regular units, how important is responsiveness?

JBG: It’s important there too. We need to know quickly who is available and who isn’t to take this patient. It’s not like in the ER, where I’m working with one person. On the floors, you’re typically working with three placements at one time or more. So you need to know what the options are for that person.

SB: If I were a provider and gave you my cellphone number and you knew that I would respond right away, would that be a big deal to you?

JBG: That’s huge. The quicker we can get to a provider, the quicker they can respond to us and come up with a quality solution to meet the discharge need. They’re going to be at the top of the list.

SB: The list — it feels like a magical list. How does an agency get on the list and how many agencies are on it? In the area where you work, I would imagine there are a lot of options.

JBG: There aren’t hundreds and hundreds [on the home care list]. It’s probably about 20. Any agency can be on our list. Our [hospital] secretary is the one that makes up the list. It’s just from known agencies — whoever we know about will be put on that list. So if somebody isn’t on that list they just need to call the hospital and talk with the secretary and let them know that they have a home care agency and ask to be put on the list.

We want them on the list. The list needs to be as comprehensive as possible.

As far as nursing homes go, all the nursing homes in the area are on the main list. And then for each insurance company, all the nursing homes that they cover/pay at, are on those lists.

SB: What about assisted living? Do you often refer directly to assisted living or is it more skilled nursing and home health?

JBG: It’s definitely most skilled nursing because of the high level of acuity in the hospital. Then next would be home health.

SB: I imagine you don’t tell the patients and their families, “Call all these 20 agencies.” How does a provider get a leg up? I assume that you say, “Here’s the list, but check out some of these folks”?

JBG: I pretty much have to. You know who you’ve worked with in the past and who’s been able to give you really good service. Are they really timely? How responsive are they to your needs and how well do they work with the families? Are they willing to drop what they’re doing and come out to the hospital and talk to the families, themselves?

SB: How important are relationships? I think about lists and names and contact information, and it’s very impersonal. Does it matter if you know who those providers are?

JBG: Realistically, absolutely. Just handing over a list or just looking at a list of a bunch of vacancies, how would you know which [to suggest]? Developing a relationship with somebody from the agency [or community] of course is going to make a difference.

SB: If you knew that I had a home care agency and had caregivers certified in dementia care, would that help you be able to filter and say, I know these guys have caregivers that specialize in this?

JBG: That would be wonderful. Anytime you have somebody specializing in something, that’s better than a general [care service]. Having a specialty is good. If your loved one has Alzheimer’s and the people are trained to know how to care for that, then they are going to be invaluable.

SB: How can a provider build a stronger relationship with a discharge planner?

JBG: Just talking to the individual person [the discharge planner] and letting them know what they have that might make them stick out. Do they have a specialty? Do they have specialty training? Anything to make them stick out and not just be a name on a list is going to be helpful.

Written by Emily Study