Discharge handoff checklist — goal: start care within 48 hours

You already run the clinical side of a homegoing. We cover the non-medical hours that keep the house workable once skilled visits are set — bathing help, meals, companionship, and steady presence from Killeen through Austin to San Antonio.

Our commitment is simple: when a referral fits our lane, we move toward a start of care as soon as the household and staffing allow. Submitting a referral is not the same as booking a start. The steps below are the path we want every partner to use.

When to refer

Refer when needs have risen above what family can cover alone, but still sit below medical or skilled nursing. Everyday examples: help with bathing and dressing, meal prep, someone in the house for evenings, or planned respite so a family caregiver can sleep.

If the primary gap is nursing, therapy, wound care, or another licensed order, keep that clinical. We are complementary, not a substitute.

For a fuller scope FAQ, see the Care article When to refer to non-medical care vs keep it clinical under News & Updates.

Timing goal

Goal: Care starts within 48 hours

It is a goal, not a guarantee for every referral.

How to submit a referral

  1. Open the partner form on the Refer Now page (for-partners).
  2. Complete the fields on that page. Share initials or an internal reference only — do not put full clinical charts in the form.
  3. Submit. The form states clearly that a referral does not book a start of care by itself.
  4. If you need a human on the line while you are building the discharge plan, call (512) 888-9105. Prefer the form so the referral is in writing.
Partner referral form beside the Referral received confirmation

What to expect after you submit

  • We receive the referral through the partner channel.
  • We review whether the need fits non-medical scope and whether we can staff the area and timing you flagged.
  • We follow up to coordinate next steps with the contacts you named.

We call the client or the family member you designate first. That person hears from us within one business day.

Consult

When the referral looks like a fit, we schedule a free in-home consult with the household. That conversation is about what help they want at home, what they do not want, and whether our services match.

Start of care

Start of care means non-medical hours begin under a service plan the household has agreed to — not the moment the form is submitted.

Before day-one hours begin, we need:

  • Signed care documents
  • An assessment completed by Sovereign Serenity Care
  • An individualized service plan we generate

Goal: Care starts within 48 hours

If something blocks that start, we say so plainly rather than quietly slipping the date.

Loop back with the referrer

After we engage, we close the loop with you so your chart and the family’s plan stay aligned. The named referrer hears from us when the consult is booked, when care starts, and whenever the status changes.

Next step

Use the Refer Now button below to open the partner form. Call (512) 888-9105 if you need us while discharge is in motion.