You're trying to close a case before shift change. We're trying to make sure a patient doesn't come back through the ED next week. Those two goals line up — so we've designed intake, documentation, and handoff around how hospital discharge teams actually work.
Every referral gets a real response within one business day — not an auto-reply.
No cost for qualifying patients on MA, UCare, BCBS, Medica, or Hennepin Health.
Secure online form, fax, phone, or direct email. Whatever your system supports.
Written progress notes to the referring team for the duration of the stay.
This is what the path looks like end-to-end. Nothing about it needs to be learned — it's designed around the documents and steps your team already produces.
Secure web form, fax (952) 400-3300, or phone. H&P and face sheet help most.
Our nurse confirms clinical eligibility and runs a real-time coverage check.
We contact you to confirm discharge date, transport, and a written plan of care.
Patient admitted at 4045 Washington St NE. Your team gets a documented handoff.
None of these are deal-breakers — we'll still review a partial packet. Having them up front just means admission can happen on the discharge date instead of a day later.
If your role involves closing a discharge plan for a patient without stable housing, you already work with someone whose case we'd take.
Inpatient social workers and discharge planners at Twin Cities and greater-MN hospital systems.
Care coordinators and case managers at UCare, Blue Cross Blue Shield, Medica, and Hennepin Health.
Shelter staff, outreach teams, FQHC social workers, and community health workers.
“It's the only recuperative-care program I've worked with where I can call a nurse, get a decision the same day, and know the patient will get a written plan of care before admission.”
Open the secure referral form or pick up the phone. We'll take it from here.
