Episodes of Care
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