Professional Resources

A Home Care Partner You Can Rely On for Your Clients

👥 For Social Workers & Case Managers · 📍 Houston & surrounding areas · ⚡ 24–48 hr placement available

When you refer a client to a home care agency, your professional reputation goes with that referral. You need to know the agency will follow through — with a qualified caregiver, clear communication, and care that actually matches what your client needs.

CareWorks Houston works alongside hospital social workers, discharge planners, insurance case managers, and community health professionals across the Houston area. We understand the pressures of your work — the tight discharge timelines, the complicated family situations, the clients who need more than just a warm body in the room. We are here to make your job easier, not harder.

Who We Work With

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Hospital Social Workers & Discharge Planners

We help patients transition safely from hospital to home — reducing readmission risk and giving families the support they need from day one.

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Insurance & Agency Case Managers

We work within care plans, document thoroughly, and keep you informed so your clients stay on track and your caseload stays manageable.

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Community & Nonprofit Social Workers

From county health departments to faith-based organizations, we partner with community professionals who connect vulnerable clients to in-home support.

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Medicaid PHC, FC & CAS Programs

We are an approved provider for Texas Medicaid’s Primary Home Care (PHC), Family Care (FC), and Community Attendant Services (CAS) programs — making us a direct fit for clients referred through HHSC and MCOs.

1 in 5 Medicare patients are readmitted within 30 days of discharge

74% of adults 50+ want to remain in their own home as they age

24–48h typical caregiver placement time after referral

100% of caregivers background-checked before placement

Why home care matters for discharge planning: Research consistently shows that patients who return home with structured in-home support have significantly lower 30-day readmission rates than those discharged without follow-up care. A reliable home care partner is one of the most effective tools in your discharge toolkit.

Services We Provide for Your Clients

We offer a full range of non-medical in-home care services, tailored to each client’s care plan and adjusted as needs change over time.

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Personal Care

Bathing, grooming, dressing, and hygiene assistance delivered with dignity and respect.

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Medication Reminders

Ensuring clients take the right medications at the right time — a critical factor in post-discharge outcomes.

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Meal Preparation

Nutritious, diet-appropriate meals prepared at home — especially important for clients with diabetes, heart disease, or swallowing concerns.

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Transportation & Appointments

Getting clients to follow-up appointments, therapy sessions, and errands safely and on time.

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Dementia & Memory Care

Specialized support for clients with Alzheimer’s or other dementias, including behavioral management and structured daily routines.

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Mobility & Fall Prevention

Transfer assistance, safe ambulation, and home environment monitoring to reduce fall risk — especially in the first weeks post-discharge.

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Companionship

Social engagement, conversation, and emotional support for clients at risk of isolation and depression.

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Overnight & Live-In Care

24-hour care options for clients with complex needs, safety concerns, or family caregivers who need overnight relief.

How the Referral Process Works

We have kept the process simple on purpose. You have enough to manage — referring a client to us should take minutes, not hours.

Step One

Submit a Referral

Use our online referral form or call us directly. Share the client’s basic information, care needs, location, and timeline. If it is an urgent discharge situation, flag it — we prioritize those immediately.

Step Two

We Confirm and Assess

A care coordinator contacts the client or family within hours to confirm details and schedule a care assessment. We review the discharge paperwork or care plan you share and build our approach around it.

Step Three

Caregiver Match & Introduction

We match the client with a caregiver whose skills and experience fit their specific needs. Where possible, we arrange a brief introduction before care begins — because familiarity matters, especially for clients with dementia or anxiety.

Step Four

Care Begins — You Stay Informed

Care starts on the agreed schedule. With the client’s consent, we keep you updated on how things are going. If anything changes — the client’s condition, their schedule, or a concern about safety — we will contact you promptly.

Step Five

Ongoing Partnership

Care plans are not static. We adjust services as the client’s needs evolve, coordinate with other care providers when needed, and are always available when you have questions. Think of us as an extension of your care team.

What You Can Expect from Us

When you refer a client to CareWorks Houston, here is what we commit to — every time.

✓ Fast response: We acknowledge every referral within 2 hours during business hours. For urgent discharges, we move faster.
✓ Honest communication: If we cannot meet a particular need — whether due to availability, geography, or scope of care — we tell you upfront so you can make other arrangements without losing time.
✓ Qualified caregivers: Every caregiver on our team is background-checked, reference-verified, trained, and insured before they step into a client’s home.
✓ Consistent care: We assign a primary caregiver to each client rather than rotating staff. Consistency matters — especially for your clients with cognitive decline or complex medical histories.
✓ Documentation and updates: We maintain visit notes and care logs, and share updates with you and your team (with client consent) so everyone stays on the same page.
✓ Respect for your clients: Your clients are our clients. We treat every person in our care with the dignity, patience, and respect they deserve — and we hold our caregivers to that standard without exception.

🏥 Hospital discharge support: For clients coming directly from a hospital or rehabilitation facility, we can coordinate with discharge planners to have a caregiver in place on the day the client arrives home. If you are working against a tight discharge timeline, call us directly — do not wait for the form.

“I have worked with a lot of home care agencies over the years. What sets CareWorks apart is that they actually communicate. I know what is happening with my clients, and when something changes, they call me. That kind of reliability is hard to find.”

Houston-area hospital social worker

Shared with permission · Name withheld for privacy

💡 A note on payment: We accept private pay, long-term care insurance, and Texas Medicaid programs — Primary Home Care (PHC), Family Care (FC), and Community Attendant Services (CAS). If your client’s funding situation is complicated, call us — we will work through it with you and help the family understand their options quickly.

More Support Options for Clients and Families

CareWorks works with trusted partners to help families access the right mix of home care, community support, and care planning resources. These partnerships can be especially helpful when a client needs more than one type of support after discharge or during a change in health needs.

CareScout Partnership

Our CareScout partnership helps eligible clients and families connect home care services with long-term care planning and support resources. It can make the process clearer for families who are trying to understand care options, benefits, and next steps after a health change or increased need at home.

Silver Heart Care Partnership

Through our Silver Heart Care partnership, clients may benefit from both professional in-home care and added community-based support. This can help reduce gaps in care by connecting seniors with practical help such as companionship, local support services, and other resources that improve safety and daily living at home.

Frequently Asked Questions

How quickly can CareWorks Houston place a caregiver?

In most cases, we can place a caregiver within 24–48 hours of receiving a referral. For urgent hospital discharge situations we work to expedite placement and will be upfront with you about what is available on short notice. If we cannot meet your timeline, we will tell you immediately so you can explore other options without delay.

What insurance or payment types do you accept?

We accept private pay, long-term care insurance, and Texas Medicaid programs including Primary Home Care (PHC), Family Care (FC), and Community Attendant Services (CAS). If a client is enrolled in a Medicaid MCO or referred through HHSC, we are set up to work within those systems. If you are unsure whether a client’s coverage applies, call us and we will confirm quickly.

Will I receive updates on my client after the referral?

Yes, with your client’s written consent. We provide care updates to referring professionals and are available by phone or email whenever you have questions about a client’s status. If something changes — an incident, a health concern, a change in the client’s condition — we will contact you promptly.

What geographic areas do you serve?

We serve Houston and the surrounding communities including Sugar Land, Katy, The Woodlands, Pearland, Pasadena, Friendswood, and other areas in Harris, Fort Bend, Montgomery, and Brazoria counties. If you are unsure whether we serve a specific zip code, call us and we will check immediately.

Can you work alongside other providers — home health nurses, therapists, hospice?

Absolutely. We regularly coordinate alongside skilled home health agencies, physical and occupational therapists, hospice teams, and other care providers. We are non-medical caregivers, so we complement rather than duplicate clinical services. Clear communication between all providers is something we prioritize.

What happens if a caregiver is sick or unavailable?

We maintain backup caregiver coverage for every client. If a primary caregiver cannot make a scheduled visit, we notify the client and family promptly and arrange a qualified substitute. We do not leave clients without coverage, and we do not leave referring professionals to find out about problems after the fact.

Ready to Refer a Client?

Submit a referral and a CareWorks care coordinator will follow up within 2 hours. For urgent discharge situations, call us directly — we move fast when time matters.

Prefer to talk first? Call us at 832-237-2273 · Mon–Fri 8am–6pm, Sat 9am–2pm

Sources & Citations

Jencks, S.F., Williams, M.V., & Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360(14), 1418–1428. doi:10.1056/NEJMsa0803563
AARP Public Policy Institute. (2021). 2021 Home and Community Preferences Survey. Washington, DC: AARP. aarp.org
Naylor, M.D., & Keating, S.A. (2008). Transitional care: Moving patients from one care setting to another. American Journal of Nursing, 108(9 Suppl), 58–63. PubMed
U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. (2020). Long-term services and supports for older Americans: Risks and financing. Washington, DC: ASPE. aspe.hhs.gov
Coleman, E.A., Parry, C., Chalmers, S., & Min, S.J. (2006). The care transitions intervention: Results of a randomized controlled trial. Archives of Internal Medicine, 166(17), 1822–1828. PubMed