Referral Packet Review

Referral Packet Review

Help SNF admissions staff (admissions coordinators, admissions directors, clinical liaisons) screen an inbound hospital referral and decide whether to accept, decline, or hold pending more information. The end product is always a decision memo in the exact format under "Output format" below — consistent structure lets teams compare referrals side by side and hand the memo to a DON or administrator without rework.

Work in this order: intake → clinical screen → financial screen → red flags & missing info → decision memo. Do not skip ahead to a recommendation before both screens are done — a patient can be a perfect clinical fit and still be a decline on payer terms, or vice versa.

Step 1 — Intake: get the packet

Ask the user for the referral content in whatever form they have:

• Pasted text — face sheet, H&P, discharge summary, med list, therapy notes, case-manager message. Any fragment is usable; note what is missing.
• PDF file paths — if the user gives file paths, read the PDFs directly. Referral packets are often scans; if a PDF has no extractable text, tell the user and ask them to paste the key pages instead.
• A verbal summary — sometimes the liaison only has a phone report. Proceed, but mark every unverified fact as "per verbal report" in the memo.

Also ask up front (these change the whole analysis, so get them early):

1. Which payer is listed? (exact plan name as written on the face sheet)
2. Referring hospital and target discharge date — urgency drives how hard to push on missing documents versus deciding on what is in hand.
3. Anything the facility already knows it cannot support? (e.g. no vent capability, no bariatric beds) — saves screening time.

If the user has multiple documents, review all of them before analyzing. Newer documents supersede older ones (a discharge med list beats an admission med list).

Step 2 — Clinical screen

Extract and assess, in this order:

1. Diagnoses — primary reason for the SNF stay, plus active comorbidities. Distinguish the skilled need (why SNF-level care is required) from background history. Medicare-covered SNF care requires a daily skilled nursing or therapy need — if you cannot articulate one from the packet, flag it.
2. Acuity and stability — recent ICU stay, unresolved infections, pending procedures, recent falls, unstable vitals mentioned in notes. A patient who is not medically stable for SNF transfer is a hold, not an accept. For very high acuity (active vent weaning, ongoing instability), first ask whether the patient is SNF-appropriate at all versus LTACH-level care — settle level of care before capability screening.
3. Special care needs — scan explicitly for each high-impact need: IV therapy/central lines, wound care and wound vac, dialysis, ventilator or tracheostomy, behavioral/psychiatric needs, bariatric accommodation, isolation precautions (MDRO, C. diff, respiratory), tube feeding, oxygen/respiratory therapy, and complex medication regimens. Read references/clinical-capability-screen.md for the full checklist: what to look for in the packet for each need, and the capability question to ask the facility. That file is the authoritative list — consult it on every review rather than screening from memory.
4. Therapy needs and functional status — prior level of function, current mobility/ADL status, anticipated PT/OT/SLP needs, weight-bearing restrictions. This matters both clinically (can the patient participate?) and financially (therapy drives payment and level-of-care under many contracts).
5. Cognition and behavior — dementia, delirium, elopement risk, aggression, substance use. These determine unit placement and staffing, and are the most commonly under-disclosed items in referral packets.

For every need identified, ask the user whether the facility supports it before finalizing the memo — never assume capability. Phrase it concretely ("Do you have staff competent to manage a wound vac on all shifts?"), because "we do wound care" and "we can manage a wound vac 24/7" are different answers. Any need the facility cannot support is grounds for decline or for negotiating with the hospital (e.g. "accept after the picc line is removed"). If the user cannot confirm a capability in time, mark the memo "Capability: UNCONFIRMED" for that need — the recommendation then cannot exceed "Hold — need more information" or "Accept pending authorization."

Step 3 — Financial screen

1. Classify the payer from the exact plan name: Medicare FFS (traditional Part A), Medicare Advantage, Medicaid FFS, managed Medicaid, commercial, VA/other. If the plan name is ambiguous (many MA plans and managed Medicaid plans have similar names), say so and tell the user to verify with an eligibility check before admission. Read references/payer-screening-guide.md for the per-payer screening questions, qualifying-stay rules, and prior-auth likelihood — use it on every review.
2. Qualifying stay — for Medicare FFS, confirm the 3-day inpatient hospital stay requirement (observation days do not count) and remaining benefit days. Note that CMS waivers and certain ACO/alternative-payment arrangements can modify this — tell the user to verify current rules rather than assuming.
3. Prior authorization — Medicare FFS generally requires none; MA, managed Medicaid, and commercial almost always do. If auth is required and not in the packet, the memo's recommendation cannot be "Accept" — at most "Accept pending authorization."
4. High-cost items — flag anything that erodes margin on a per-diem payment: specialty/brand medications (IV antibiotics, anticoagulants, biologics, antiretrovirals, oncology drugs), dialysis transport and treatment, wound vac rentals, isolation supplies and cohorting costs, bariatric equipment rental, 1:1 supervision needs. Do not quote drug prices or reimbursement rates — they change constantly; instead list the items and tell the user to price them against the current contract or PDPM estimate.
5. Reimbursement drivers — for Medicare FFS, payment follows PDPM: the clinical picture (primary diagnosis mapping, nursing needs, NTA comorbidities, function scores) determines the per-diem. Note in the memo which packet facts are likely PDPM-relevant. For a deeper analysis, the companion pdpm-estimate and nta-score-capture skills (if installed) can build a component-level estimate — suggest them rather than estimating rates yourself. Never state dollar figures for rates; refer the user to the current CMS SNF PPS final rule, their MAC, or their contracts for numbers.

Step 4 — Red flags and missing information

Check the packet against this list of commonly missing items. Anything absent goes in the memo's "Request from hospital" list, worded so the user can paste it directly into a message to the discharge planner:

• Current medication list (with last-administered times for time-critical meds)
• History & Physical (H&P)
• Discharge summary (or interim summary if not yet discharged)
• Recent physician progress notes
• PT/OT/SLP evaluations and most recent therapy notes
• Insurance card copy (front and back) and any authorization number already obtained
• Code status / POLST / advance directive
• Recent labs (especially if on anticoagulants, antibiotics, or dialysis)
• Wound documentation with measurements and photos if available
• Behavioral health notes if any psychiatric history is mentioned
• Culture results / infection status for any isolation-relevant organism
• Demographics and emergency contact / responsible party
• Court documents if guardianship or conservatorship is referenced

Red flags to call out explicitly (these are the items that most often turn into post-admission surprises): vague or missing skilled need, a med list that mentions "see MAR" without the MAR, behavioral history described only in passing, pending test results, "family issues" noted without detail, a prior SNF stay that ended in discharge against medical advice or facility-initiated discharge, and any mismatch between the verbal report and the written record.

Step 5 — Write the decision memo

Fill in the template below completely. Rules:

• Recommendation is one of: Accept / Accept with conditions / Accept pending authorization / Hold — need more information / Decline. "Accept with conditions" must state the conditions (e.g. "pending auth approval," "after picc removal").
• Every risk and every missing item identified in Steps 2–4 must appear in the memo — the memo is the paper trail if the decision is questioned later.
• Keep the rationale to a few sentences a busy administrator can read in under a minute; put detail in the sections above it.
• Use only information from the packet and the user's answers. Never invent clinical facts; write "not documented" where the packet is silent.

Output format

# Referral Decision Memo

**Patient:** [initials or first name + last initial only] | **Referring hospital:** [name]
**Target discharge date:** [date or "not stated"] | **Reviewed:** [today's date]
**Reviewed by:** [user's name/role] with AI assistance

## Patient summary
[2-4 sentences: age/sex if given, primary reason for SNF stay, key comorbidities,
functional status, disposition goal (short-term rehab vs long-term care).]

## Clinical fit
| Need identified | Source in packet | Facility can support? |
|---|---|---|
| [e.g. IV antibiotics via PICC, 10 more days] | [H&P p.2] | [Yes / No / Unconfirmed] |

**Skilled need:** [one sentence stating the daily skilled nursing/therapy need, or "unclear — see risks"]
**Therapy outlook:** [anticipated PT/OT/SLP involvement and functional goals]

## Financial fit
- **Payer:** [plan name as written] — classified as [Medicare FFS / MA / Medicaid / managed Medicaid / commercial / unverified]
- **Qualifying stay (if Medicare FFS):** [met / not met / unverified — details]
- **Prior authorization:** [not required / required — status]
- **High-cost items:** [list, or "none identified"]
- **Reimbursement notes:** [PDPM-relevant facts for FFS; contract/leveling notes otherwise; suggest pdpm-estimate / nta-score-capture skills if a deeper estimate is wanted]

## Risks
1. [Each clinical, financial, or documentation risk, one line each, worst first]

## Missing information — request from hospital
- [ ] [Item 1]
- [ ] [Item 2]

## Recommendation: [Accept / Accept with conditions / Accept pending authorization / Hold — need more information / Decline]
**Conditions (if any):** [list]
**Rationale:** [2-4 sentences tying clinical fit + financial fit + risks to the recommendation]

## Follow-ups
- [ ] [Who does what by when — e.g. "Verify eligibility before transport", "Confirm wound-vac staffing with DON"]

After presenting the memo, offer to draft the "request from hospital" message to the discharge planner as ready-to-send text.

Disclaimer

This skill is an educational and workflow aid. Verify all coverage, payment, and regulatory conclusions against current CMS rules (including the current SNF PPS final rule), your state regulations, and your facility's payer contracts before acting. Nothing here is clinical, billing, or legal advice; admission decisions remain the responsibility of the facility's licensed and authorized staff.