SNF Discharge Planning Coordination
We run structured SNF discharge planning under the IMPACT Act for every short-stay and long-stay resident. MDS Section GG functional discharge goals, Section A2400 and A2300, hospice referrals, home health transitions, DME orders, and 30-day readmission risk scoring. 800+ providers trust us. Pilot in 2 weeks.
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0:48Your discharges leak. Your 30-day readmits keep climbing .
Three discharge failures quietly damage SNF performance every month. Each one starts when Section GG goals are not set early, and each one ends with a readmit, a hospital partnership frayed, or an IMPACT Act survey finding.
Section GG discharge goals never set
The MDS Section GG admission entry requires a functional discharge goal for self-care and mobility. If the goal is missing, the IMPACT Act standardized assessment data set is incomplete and survey citations follow.
Home health handoff dropped
When the discharge planner does not loop in the home health intake nurse 48 hours before SOC, the home health window closes, the resident sits at home without skilled visits, and the 30-day readmit risk doubles.
Readmit risk untracked
Without a readmission risk score on file at discharge, the SNF cannot identify the residents who need extra follow-up calls. The 30-day SNF Readmission Measure suffers and the next hospital referral list shrinks.
Tell us about your agency.
Send us your situation and our team will scope the right setup, usually within one business day. No obligation.
What is SNF discharge planning coordination ?
SNF discharge planning coordination is a remote discharge planning specialist who runs every IMPACT Act required step from admission day through 30 days post-discharge. Not a generic care coordinator. Not a part-time social worker. A trained discharge planner who sets MDS Section GG functional discharge goals, completes Section A2400 prior inpatient stay tracking, documents Section A2300 discharge status, manages home health and hospice handoffs, and tracks the 30-day SNF Readmission Measure.
What your SNF discharge planner actually handles, day to day
Pick the discharge workflows that hurt most. Your discharge planner absorbs them. Your on-site social worker focuses on family conversations and complex psychosocial cases.
Section GG discharge goals
Sets the Section GG self-care and mobility discharge goals at admission. Tracks the IMPACT Act standardized assessment data set so the discharge MDS closes complete and on time.
Section A2400 tracking
Captures the most recent prior inpatient stay data required by Section A2400. Documents the source, dates, and reason for prior admission so transitions are clean.
Section A2300 discharge status
Codes the discharge return-anticipated status, discharge to community indicator, and the discharge location. Ensures the SNF QRP data set is complete on the day of discharge.
Home health handoff
Coordinates the home health intake 48 to 72 hours before the SOC visit. Pushes face-to-face encounter notes, plan of care, and OASIS-required data to the home health intake nurse.
Hospice referral
Files hospice referrals when goals shift to comfort care. Coordinates the hospice election form, attending physician of record, and the level-of-care change with the family.
DME orders
Places durable medical equipment orders for wheelchairs, walkers, hospital beds, oxygen, and wound care supplies. Confirms delivery before the discharge date so the home is ready.
30-day readmit risk scoring
Runs a readmission risk score using LACE, HOSPITAL, or your in-house index. Flags high-risk residents for the post-discharge follow-up call queue at 24, 72, and 14 days.
Post-discharge follow-up
Calls the resident or family at 24, 72, and 14 days post-discharge. Captures medication adherence, follow-up appointment attendance, and any new symptoms that signal a readmission.
Discharge-trained planners, not generic VAs
Most outsourcing companies offer call-center agents and call them "discharge support." We do not. Our discharge planners are IMPACT Act-tested, Section GG-trained, and EMR-certified before they ever touch a live discharge for your building.
Discharge-trained, not generic
Every planner passes an assessment on IMPACT Act discharge requirements, MDS Section GG goal setting, Section A2400/A2300 coding, home health and hospice transitions, and at least one major EMR from PointClickCare, MatrixCare, or American HealthTech before placement.
Stacked compliance posture
HIPAA + SOC 2 Type II + ISO 27001 + HITRUST. Plus alignment with the 45 CFR 164.514 de-identification standard for analytics and 42 CFR 483.21 discharge planning. Ask your current vendor for proof of all four. We will wait.
2-Week Risk-Free Pilot
Industry offers no trial. We give you 14 days of live discharge planning coordination at the same rate. Cancel before day 14, owe nothing. No annual contracts after.
Staffingly vs DIY in-house vs generic VA vs onshore BPO
The real cost math for a single full-time SNF discharge planning role at a mid-size operator.
From "let's talk" to live in 1 to 2 weeks
Six steps. Each one is documented. Nothing is mysterious.
Discovery call (15 min)
Tell us which discharge pain is loudest. Section GG goals not set? Home health handoff dropped? 30-day readmits climbing? We map it on a shared call. No prep needed from you.
BAA + EMR and home health access
Business associate agreement signed. Role-based access provisioned in PointClickCare or MatrixCare. Read access set up for your preferred home health and hospice partner systems.
Workflow shadow (2 to 3 days)
Your planner shadows your on-site social worker and DON in NJ, NY, TX, or FL. Discharge protocols captured. Family contact rules locked. Hospice and home health partners mapped.
Parallel pilot starts
Week 2 to 3. Your discharge planner runs alongside your team. Daily 15-minute sync. You see every Section GG goal set, every home health handoff, every hospice referral filed.
Decision point (end of week 2)
Pilot results reviewed. Go or no-go. No penalty if you cancel. Most operators keep going.
Full handoff, cadence locked
Discharge on-time rate, home health handoff success, 30-day readmission rate, and IMPACT Act QRP data completeness in your inbox. Weekly review with your account lead. Monthly QA audit.
How your SNF discharge planner's day actually looks
A real shift, hour by hour. Times shown in your local time. We rotate coverage so your discharge queue is never dark during business hours.
How Staffingly works, in practice
Inside the workA trained Staffingly specialist works inside your existing platform, with clear escalation back to your team.
One Flat Weekly Rate. No Surprises.
Dedicated senior care schedulers at a fixed weekly cost. Per scheduler FTE, per week. No contracts, no minimums, no hidden fees.
Want to compare against an in-house hire? Use the savings calculator.
Frequently asked questions
What are the IMPACT Act discharge requirements?
The IMPACT Act of 2014 requires SNFs to collect standardized patient assessment data on functional status, cognitive function, special services, treatments, and interventions. The data set is reported through MDS items including Section GG, Section O, and Section K. Our discharge planners track every required IMPACT Act element so the SNF QRP submission is complete on every discharge.
How are Section GG functional discharge goals set?
Section GG self-care and mobility discharge goals are set at admission based on the resident prior level of function, current admission performance, and the projected discharge setting. Our planner pulls the prior-level data from the hospital transfer note, codes admission performance with nursing and therapy, then sets discharge goals consistent with the IMPACT Act standardized assessment data set.
How are Section A2400 and Section A2300 handled?
Section A2400 captures the most recent prior inpatient stay. We pull source, dates, and reason for the prior admission and post the data in the EMR within the first 24 hours of admission. Section A2300 codes the discharge return-anticipated indicator, discharge to community status, and the discharge location. Both sections close before the discharge MDS is submitted.
How is the home health handoff coordinated?
Our discharge planner calls the home health intake nurse 48 to 72 hours before the SOC visit. We push face-to-face encounter notes, plan of care, OASIS-required clinical data, and the medication reconciliation list. The home health window opens on time and the SOC visit happens inside the 48-hour window.
How is a hospice referral filed?
When goals shift to comfort care, we file the hospice referral with the family-preferred or facility-preferred hospice agency. The hospice election form is signed, the attending physician of record is named, and the level-of-care change is coordinated so there is no service gap on the day of transition.
How is readmit risk tracked?
We run a readmission risk score using LACE, HOSPITAL, or your in-house index on every short-stay discharge. High-risk residents get scheduled follow-up calls at 24 hours, 72 hours, and 14 days post-discharge. Calls capture medication adherence, follow-up appointment status, and any new symptoms that signal a readmission.
How is the discharge planner role priced?
$399 per FTE per week at single-building rate. $349 at 3+ FTEs (volume). $299 at 10+ FTEs (enterprise). No setup fees. Flat weekly billing. Add or remove FTEs by the week. 2-Week Risk-Free Pilot at the same rate.
How does the 2-Week Risk-Free Pilot work?
You sign a short pilot order at the per-FTE weekly rate. The discharge planner runs live work for 14 calendar days. At the end of week 2, you make a go or no-go call. Cancel before day 14, owe nothing. No annual contracts after. Replacement planner at no charge if the fit is wrong.
President and CEO, Staffingly, Inc. 25+ years in IT consulting and healthcare BPO operations. One of the earliest US operators to set up an RPO/BPO delivery network in India. Leads AI-driven home care workflows that help agencies, home health providers, and multi-branch operators cut admin cost without compromising care.
