1. Getting Started with exacare for Social Workers and Discharge Planners

Last updated: September 13, 2026

Who this is for

  • Social Workers & Discharge Planners

  • Directors of Social Services

  • Anyone who leads or oversees a facility's discharge team

When to use this article

Use this as your starting point if discharge planning is your main job in exacare. It points you to the three things you'll use most day to day:

  • The Report and PDPM Estimator in the Screener — for a fast read on a patient

  • Sending Referrals — for getting a patient placed with a Home Health, Hospice, Dialysis, SNF, or LTAC provider

  • eSign — for getting discharge paperwork and consent forms signed without printing anything

Before you start

Make sure:

  • You have an exacare account. If you don't see the Screener or Outbound tab in your left-hand navigation, ask your facility administrator to grant you access.

  • You know which patient or referral you're working on — most of what's below starts from a specific resident's record.

What you'll use exacare for

1. Get a fast read on a patient with the Report and PDPM Estimator

Before you start coordinating a discharge — or when you're weighing whether to admit someone — you don't need to read through the entire referral packet by hand.

  • Report — Open any resident's record and click the Report tab to see a summary pulled from their original referral documents: diagnoses, medications, functional status, and other key details in one place. You can also see the Activity log (every status change, comment, and upload on that resident) and, for most referral sources, a Hospital Chat to message the sending hospital directly.

  • PDPM Estimator — Open the PDPM tab on a resident's referral page and click Analyze PDPM to get an estimated daily Medicare reimbursement rate, broken down across the five PDPM components (PT, OT, SLP, Nursing, and NTA). This is a pre-admission estimate built from referral documents — treat it as directional guidance for admission and level-of-care decisions, not a replacement for your MDS team's post-admission assessment.

2. Send referrals out of your facility

This is likely most of your day: getting a patient placed with the right downstream provider once they're ready to leave your facility.

  1. Open the Screener and find the resident, or go to the Outbound tab and click + Create outbound referral.

  2. Pick the referral type (Home Health, Hospice, Dialysis, SNF, LTAC, Equipment, or Other), the date you expect them to move, and the recipient.

  3. Attach documents — your admission packet is pre-attached, and you can add or remove files as needed.

  4. Send. If the recipient doesn't use exacare, they get a secure link by email — no account needed on their end.

Once sent, you can track every referral from the Outbound tab: status, a chat thread with the recipient (with read receipts), and a full activity log. The Discharge Calendar (in the Outbound tab) shows every upcoming discharge across your facility by date, so your whole team — not just you — can see what's coming.

Full instructions: How to Send an Outbound Referral

3. Get paperwork signed with eSign

For admission agreements, consent forms, and other paperwork that needs a signature, eSign replaces printing and physically routing documents for signature.

  • Send a signature request from a resident's record — fields like patient and facility information are pre-filled from the referral.

  • Signers get a secure email link (no exacare login needed on their end), or you can hand a device to a resident to sign in person on the spot.

  • Track open, pending, and completed requests from the eSign dashboard.

eSign is included at no additional cost — there's nothing to buy or configure to try it. It's a separate, optional feature from Report, PDPM, and Sending Referrals, so you can use it for admission paperwork, discharge home forms, or anything else you need signed.

FAQs

I use the Screener today for admissions — is discharge planning a separate part of exacare?

Yes. Your inbound work (reviewing referrals coming into your facility) happens in the Screener. Your outbound work (sending a patient to their next provider) happens in the Outbound tab. They're connected - you can start an outbound referral directly from a resident you already have open in the Screener.

Is the PDPM estimate the same as my MDS team's assessment?

No. It's built from pre-admission referral documents to give you a fast, directional estimate - typically accurate within about $100 of the eventual MDS-based rate. Your MDS team's post-admission assessment is still the official record.

Does exacare replace the paper or PDF packets I send with a referral today?

Yes, that's the idea! Outbound Referrals keeps the documents, dates, status, and messages with the recipient in one place instead of email or fax.

Do I need to set anything up before I can start sending referrals or eSign requests?

For most facilities, no - both are ready to use as soon as you have exacare access. If your facility uses PointClickCare or MatrixCare, ask your account lead whether the document pull integration is turned on for you, since that changes how documents get attached.