Episodes of Care

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Not all readmissions happen in the first 30-days post-hospitalization. The Episodes of Care program was designed to:

  • care for patients who need monitoring over a longer period post-discharge
  • optimize the clinical and financial performance of a bundled payment

Eligible patients include those who are in a Medicare bundled payment program, such as Total Joint Replacement or Bypass Surgery (CABG).

Similar to the Care Transitions (30-Day) program, patients are monitored daily on clinical status, self-care activities and social determinants of health. Special emphasis is placed on a patient’s ability to comply with the required doctor visits and rehabilitation therapies necessary for recovery.

Episodes of Care Program Features

  • Daily health survey accessible by phone or Internet connection
  • Survey questions tailored to assess the clinical status, self-care activities and social determinants of health
  • Care coordination worklists and alerts through the Navitas platform

Sara AldworthEpisodes of Care