A discharge planner at a hospital has a patient going home tomorrow after surgery. A few years ago, she'd have called the agencies she knew best. Today, her hospital may be financially responsible for the next 30 days of that patient's care, including what happens at home. Every referral is now part of the hospital's cost and quality results. So the questions she's asking have changed. It's less "who do I know?" and more "who answers quickly, who follows through, and who can