Follow a skilled nursing referral to an outside behavioral health provider, from intake acknowledgment to the visit summary and an assigned follow-up task.
A skilled nursing facility should send the outside provider a clear referral question, confirm that the provider accepts it, and assign someone at the facility to review the returned visit summary and own follow-up.
This guide follows a routine behavioral health referral for a resident who stays at the facility. The outside clinician documents the visit in a separate system. The facility needs to know what came back, where staff can find it, and who is responsible for the next action. Use the sample to walk both teams through the same handoff.
How should a skilled nursing facility hand off a behavioral health referral to an outside provider?
Agree on the referral question, the receiving contact, the return route, and the facility follow-up owner before sending the packet. After sending, track delivery and acceptance as separate events. When the visit is complete, verify that the designated facility reviewer can open the current summary and that any follow-up has an owner and a due date.
A perspective published by AHRQ's Patient Safety Network describes structured handoffs that include an “action list” and “synthesis by receiver.” In this sample, the receiver demonstrates that they can find the correct summary and state their next action. Start with a routine administrative scenario. Urgent concerns belong in the facility's established clinical escalation process.
Agree on the packet and the return route
Start with a referral question the outside clinician can answer. For the fictional referral BH-014, the facility asks for a consultation about concerns the care team has already documented. The facility coordinator identifies a contact for scheduling and a designated nurse for the return summary. The two organizations agree on which records they need to exchange and how staff will access them.
Create a small record map before testing the workflow. AHRQ's workflow toolkit lists flowcharts as a way “to examine the handoffs that occur in a process.” For each row, ask the person who receives the information to open it while signed in under their own role.
| Record | Where it starts | What the other team needs |
|---|---|---|
| Referral request | Facility referral record | Referral question, agreed supporting material, and facility contact |
| Acceptance | Outside provider's intake record | Acceptance status, date, and owner of the next step |
| Consult note | Outside provider's clinical record | The agreed summary or record reference, through the approved exchange |
| Facility follow-up | Facility care record or worklist | Assigned role, due date, current summary reference, and documented disposition |
Use the approved exchange for resident information. In the demo, give both systems the fictional reference BH-014 so staff can match the referral, visit, and return summary without relying on a name in a message subject line. Note which details staff can reuse from the receiving record and which they have to enter again.
Follow one referral across both teams
The example below spans two days. Its times illustrate the order of events. Use your own service expectations and coverage arrangements to decide when staff follow up.
| Sample time | Event | What staff can show | Next owner |
|---|---|---|---|
| Day 1, 09:00 | Facility sends BH-014 | Packet reference and return contact in the facility record | Facility referral coordinator tracks the response |
| Day 1, 09:10 | Packet is delivered | Receipt appears in outside intake | Facility coordinator keeps the follow-up task open |
| Day 1, 11:20 | Intake asks for a missing contact detail | Clarification request is tied to BH-014 | Facility coordinator resolves the request |
| Day 1, 13:00 | Outside intake accepts the referral | Acceptance date and scheduling contact are recorded | Outside scheduler arranges the visit |
| Day 2, 10:30 | Consultation takes place | Outside clinician records the encounter | Outside team prepares the agreed summary |
| Day 2, 14:00 | Summary reaches the facility | Facility reviewer can open summary version 1 | Designated nurse reviews it and records any follow-up |
| Day 2, 16:15 | Outside team sends a correction | Version 2 is current and version 1 remains identifiable | Facility reviewer checks whether the correction changes an open task |
Ask the facility coordinator what they would see at 09:10. Delivery should be visible and the acceptance task should still be open. At 13:00, ask where they would find the decision and who is now scheduling. The referral portal receiving workflow has a separate test for what happens when a packet reaches intake with a missing field.
Put the returned summary where the next shift can find it
At 14:00, have the designated nurse open the summary from the facility record. Ask how they can tell that it belongs to BH-014 and that it covers the visit on Day 2. Record where the received summary is kept or referenced, who reviewed it, and whether it creates work for the facility. If follow-up is needed, record the task, owner, and due date where the next shift already looks for open work.
At 16:15, ask a second staff member to take over without watching the first walkthrough. They should be able to find version 2, see who received the correction, and tell whether the facility has reviewed its effect on the open task. Give them a copy of version 1 in the sample inbox as well. Check whether the record makes it clear which version to use.
Now remove the return receipt from the scenario. Have the coordinator find the referral, see that the expected summary is outstanding, and contact the outside office through the agreed route. Repeat with a summary delivered to a shared inbox that the designated reviewer cannot access. These are different failures. Track who retrieves or reroutes the summary and how they confirm the reviewer can open it.
Give the billing teams a shared reference
Have each billing contact match the administrative encounter reference and visit date to the same referral. Ask them to record the party responsible for checking billing treatment and who will resolve a disagreement. Keep the billing question visible alongside the clinical handoff so teams can see which work each person owns.
CMS's Medicare consolidated billing overview describes bundled services and notes that certain services are “specifically excluded from consolidated billing.” Have qualified billing staff verify the applicable rules and agreements for the actual service before anyone submits a claim. For the demo, leave the decision open and ask the next biller to find the referral, the person checking it, and the record where the determination will be entered. Use the billing handoff worksheet to capture that responsibility.
Test the same handoff in both systems
Ask the facility and outside provider to work through the same fictional record. Use the EHR demo scorecard to record which role performed each check, where the evidence appeared, and any manual transfer that was needed.
| Test | Evidence to look for |
|---|---|
| The packet arrives before intake accepts it | The sending team can see delivery and still identify who owns the acceptance follow-up |
| Intake asks for a missing detail | The question and response stay attached to the original referral |
| The visit ends without a summary | Facility staff can find the open retrieval task and the expected return route |
| A correction arrives at shift change | The receiving nurse finds the current version and the owner of any follow-up |
| Both billing teams ask who submits | Staff match the same encounter and locate the owner of the billing decision |
Finish by asking someone from the next shift to reconstruct the handoff from the record. They should be able to say whether the outside provider accepted the referral, where the current summary is, and what is still open. If they have to call the sender to answer, write down the missing field, permission, or assignment. That becomes the next item to test.
Frequently Asked Questions
What goes in an outside behavioral health referral from a skilled nursing facility?
Include the referral question, the facility contact, the agreed return route, and the records the provider needs under the organizations' approved sharing process. Assign someone to track acceptance and outstanding questions.
When has the outside provider accepted the referral?
The outside team confirms that it has taken the referral and identifies who owns the next step. A delivery receipt records that the packet arrived. Track delivery and acceptance separately so incomplete referrals remain visible.
Where should the outside provider's visit summary go?
Send the agreed summary to the designated facility contact through the approved exchange. The facility records which version it received, where authorized staff can find it, and who will review it and handle follow-up.
What happens if an outside provider sends a corrected summary?
Identify the current version and keep the receipt history. Assign someone to compare the correction with any open facility tasks, record what needs to change, and confirm that the people doing the work can find the current summary.
How can I test an outside behavioral health referral in a software demo?
Use one fictional resident and run the workflow in both systems. Include a packet received before it is accepted, a late or corrected summary, and a shift change. Ask the next staff member to locate the current summary and identify the owner of each open task.
