Referral Eligibility Criteria

Our services include:

• Skilled Nursing Care — Clinical assessments, medication management, wound care, chronic disease support, and coordination with physicians.
• Rehabilitation Services — Physical, occupational, and speech therapy designed to help patients regain strength, mobility, and functional independence.
• Medical Social Work — Assistance with care planning, community resources, counseling, and support for patients and families navigating complex health needs.
• Home Health Aide Support — Personal care assistance including bathing, grooming, mobility support, and activities of daily living.
• Care Coordination — Collaboration with hospitals, clinics, and community partners to ensure seamless transitions and continuity of care.

Our mission is to deliver high‑quality home‑based healthcare that promotes dignity, safety, and improved health outcomes for San Francisco residents.

Eligibility criteria that all patients must meet for regular home health services.

• Meets CMS-defined homebound criteria.
• Meets skilled service needs criteria for Skilled Nursing, Physical Therapy.
• Meets medical eligibility for skilled intermittent home health services.

Per 1814(a) and 1835 (a) of the Social Security Act, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria One (One must be met):

1. Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person to leave their place of residence.
2. Have a condition such that leaving their home is medically contraindicated.

Criteria Two (Both must be met):

1. There must exist a normal inability to leave home.
2. Leaving home must require a considerable and taxing effort.

We accept the following coverages:

• Medicare AB, Medicare A, Medicare B
• Medi-Cal Full Scope
• San Francisco Health Plan
  • San Francisco Health Network (CHN)
  • North East Medical Services (NEMS)
  • North East Medical Services with San Francisco Health Network (NMSS)
  • University of San Francisco (UCSF)
• Healthy Worker
• Healthy San Francisco
• HIV CARE Contract

If you are a provider within the San Francisco Health Network, you can send the referral via Epic EHR.

If you are a provider outside of the network and do not have access to Epic, then you may fax the referral to our Intake Fax line at 628-754-4765.