Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Discharge needs × insurance coverage

42 need categories × 4 payer types · with partner integrations + PA TAT + denial reasons

Discharge map Dispositions (UB-04)Post-acute services Logistics Needs × coverage Resource hub Insurance plans

Every patient leaves with a constellation of needs. Throughline checks coverage for each need against the patient's specific plan in real-time, drafts the prior auth packet when required, surfaces partner integration paths, and flags common denial reasons before submission. Below: the matrix view, then per-need workflow detail grouped by category.

Coverage matrix

42 need categories × 4 payer types

Need	Cat.	Medicare FFS	Medicare Advantage	Medicaid	Commercial	PA TAT
℞ Oral medications owner: Pharmacy / Pharm Tech	Medications	Tiered formulary Part D plan-specific tiering; PA + step therapy common	Tiered formulary MAPD plan tiering; PA + step therapy	Covered (PA req) State preferred drug list; PA on non-preferred	Tiered formulary Plan formulary; PBM rules	1–24h (CoverMyMeds real-time decision in 40% of cases)
✦ Specialty pharmacy (biologics, oral oncology) owner: Pharmacy / Case Manager	Medications	Tiered formulary Part D specialty tier (Tier 5/6); high coinsurance	Tiered formulary MAPD specialty tier + PA	Covered (PA req) Step + PA + quantity limits	Covered (PA req) Carve-out to Accredo, CVS Specialty, Optum Specialty	24–72h (manufacturer hub + payer PA serial)
⚕ IV infusion at home (OPAT, biologics) owner: Pharmacy / Case Manager / MD	Medications	Covered (PA req) Part B for drugs + DME pump; Part D for some self-administered	Covered (PA req) PA + benefit varies	Covered (PA req) State PA; specialty pharmacy carve-out	Covered (PA req) Specialty pharmacy carve-out + PA	24–72h
◌ Total parenteral nutrition owner: Pharmacy / Nutrition / Case Manager	Medications	Covered (PA req) Part B + LCD criteria (90+ days gut failure documented)	Covered (PA req) PA + necessity review	Covered (PA req) State PA	Covered (PA req) Specialty pharmacy + PA	3–7 days (LCD criteria documentation)
◔ Enteral feeding (G-tube / PEG / NJ) owner: Nutrition / Case Manager	Durable medical equipment	Covered (PA req) Part B enteral nutrition + pump + supplies (LCD L33783)	Covered (PA req) PA + LCD-equivalent	Covered (PA req) State PA	Covered (PA req) PA + tier	48–96h
○ Home oxygen owner: Case Manager / RN	Durable medical equipment	Covered (PA req) Part B DMEPOS; 36-mo capped rental; LCD L33797	Covered (PA req) PA + plan-specific vendors	Covered (PA req) State PA + LCD-equivalent	Covered (PA req) PA + in-network vendor	8–48h (vendor + payer concurrent)
≋ CPAP / BiPAP owner: Pulmonology / Case Manager	Durable medical equipment	Covered (PA req) Part B; 90-day compliance requirement (4h/night ≥ 70%)	Covered (PA req) PA + adherence	Covered (PA req) State PA	Covered (PA req) PA + adherence	48–96h
≡ Nebulizer + respiratory meds owner: RN / Case Manager	Durable medical equipment	Covered Part B DMEPOS + meds	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA + tier	24–48h
♿ Mobility DME (walker, wheelchair, commode) owner: OT / PT / Case Manager	Durable medical equipment	Covered (PA req) Part B DMEPOS; HCPCS-coded; 20% coinsurance	Covered (PA req) PA + in-network DME	Covered (PA req) State PA	Covered (PA req) PA + tier	24–48h (manual walker often same-day)
≣ Hospital bed at home owner: Case Manager / OT	Durable medical equipment	Covered (PA req) Part B DMEPOS LCD; necessity documented	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) PA + tier	48–72h
⌂ Home safety modifications owner: OT / Social Worker	Social determinants	Not covered Not Medicare benefit	Covered SDOH benefit in some MA plans (Humana, Aetna)	Covered (PA req) Some HCBS waivers fund environmental mods	Not covered Charity / private pay	1–3 weeks (charity intake)
✚ Wound care supplies + skilled visits owner: Wound RN / Case Manager	Skilled services	Covered HH benefit + DMEPOS supplies under Part B	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) PA + tier	24–48h
◓ Negative-pressure wound therapy (NPWT VAC) owner: Wound RN / Case Manager	Durable medical equipment	Covered (PA req) Part B + LCD; medical necessity	Covered (PA req) PA + necessity	Covered (PA req) State PA	Covered (PA req) PA + tier	24–72h
◊ Ostomy supplies + WOCN follow-up owner: WOCN / RN / Case Manager	Durable medical equipment	Covered Part B DMEPOS; quantity limits per LCD	Covered (PA req) PA	Covered State coverage with limits	Covered (PA req) PA + tier	24–72h
◐ Urinary supplies (catheter, leg bag) owner: RN / Case Manager	Durable medical equipment	Covered Part B; monthly quantities per LCD	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA	24–72h
◇ Tracheostomy supplies + RT follow-up owner: RT / Case Manager	Durable medical equipment	Covered Part B DMEPOS	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA + tier	48–72h
⊙ Diabetes supplies (CGM, strips, pens, lancets) owner: Pharmacy / CDE / Case Manager	Durable medical equipment	Covered (PA req) Part B CGM (qualifying criteria); Part D for strips/needles	Covered (PA req) PA + tier	Covered State coverage with PA on CGM	Covered (PA req) PA + tier	24–72h
♡ Cardiac monitoring (event monitor, ILR, CardioMEMS) owner: Cardiology / Case Manager	Durable medical equipment	Covered (PA req) Part B + LCD criteria	Covered (PA req) PA + necessity	Covered (PA req) State PA	Covered (PA req) PA + tier	48–96h
≈ Outpatient dialysis (HD, PD, home) owner: Nephrology / Case Manager	Skilled services	Covered Part B ESRD benefit (immediate eligibility)	Covered (PA req) PA + in-network	Covered (PA req) State PA	Covered (PA req) PA + 30-mo coordination then Medicare	24–72h (chair-limited)
✻ Oncology supportive (anti-emetics, GCSF, growth factors) owner: Oncology / Pharmacy / Case Manager	Medications	Covered (PA req) Part B for infused; Part D oral	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) Specialty pharmacy + PA	24–72h
✸ Palliative meds + symptom kit owner: Hospice MD / Hospice RN / Pharmacy	Medications	Covered Hospice benefit covers meds	Covered Carved back to Medicare hospice	Covered Hospice benefit	Covered Most plans cover hospice	Same day (hospice benefit)
✚ MAT (buprenorphine, methadone, naltrexone) owner: Addiction Med / Social Worker / Pharmacy	Medications	Covered Part D + Part B for office-based	Covered (PA req) PA	Covered Federal mandate covers MOUD	Covered MHPAEA parity	Same day to 72h
✤ Mental health follow-up owner: Social Worker / Psychiatry / Case Manager	Skilled services	Covered Part B; MHPAEA parity	Covered (PA req) PA + network	Covered Behavioral health carve-out per state	Covered MHPAEA parity	3–7 days (slot-limited)
✿ Discharge vaccinations (flu, RSV, COVID, pneumo) owner: RN / Pharmacy	Medications	Covered Part B + Part D (varies by vaccine)	Covered Plan covered	Covered State VFC program	Covered ACA preventive	Same day
✎ Disease + medication education owner: RN / Pharmacy / AI Agent	Education & teaching	Covered Bundled into DRG	Covered Bundled	Covered Bundled	Covered Bundled	Same day
→ Transport home / to next setting owner: Case Manager	Skilled services	Patient pay NEMT not routinely covered	Covered (PA req) Supplemental NEMT benefit (rides/year)	Covered (PA req) NEMT broker (state)	Patient pay Generally patient-pay	24h (≥48h advance ideal)
✿ Food + nutrition owner: Dietitian / Social Worker	Social determinants	Not covered Not standard Medicare	Covered Many MA plans cover post-DC meals (14d) as SDOH benefit	Covered (PA req) Some HCBS waivers	Not covered Charity-funded	2–5 days
⌂ Housing + SDOH supports owner: Social Worker / Community Health Worker	Social determinants	Not covered Not Medicare scope	Covered (PA req) Some MA plans fund SDOH partnerships	Covered (PA req) 1115 waivers; in-lieu-of services in select states	Not covered Charity	Days to weeks (community capacity)
✛ Skilled home health (RN / PT / OT visits) owner: Case Manager / RN	Skilled services	Covered Part A/B HH benefit; homebound + skilled need (42 CFR §409.42-43); $0 copay; CA Review Choice Demonstration applies	Covered (PA req) PA + visit management via naviHealth/UM	Covered (PA req) State PA; skilled need documented	Covered (PA req) PA + visit limits	24–72h (start-of-care)
➶ Outpatient PT / OT owner: PT / OT / Case Manager	Skilled services	Tiered formulary Part B therapy; 20% coinsurance; KX modifier required above $2,410 threshold (2025)	Covered (PA req) PA + visit caps	Covered (PA req) State PA; EPSDT for under-21	Covered (PA req) PA + visit limits + copay	3–7 days (scheduling-limited)
♥ Cardiac rehabilitation owner: Cardiology / Case Manager	Skilled services	Covered (PA req) Part B; NCD 20.10 / 20.10.1; up to 36 sessions over 36 weeks; qualifying diagnosis required	Covered (PA req) PA + in-network CR site	Covered (PA req) State PA; coverage varies	Covered (PA req) PA + copay per session	1–2 weeks (program slot)
⊛ Pulmonary rehabilitation owner: Pulmonology / Case Manager	Skilled services	Covered (PA req) Part B; NCD 240.8; moderate-to-very-severe COPD (GOLD II–IV); expanded to post-COVID; ≤ 36 sessions	Covered (PA req) PA + network	Covered (PA req) State PA	Covered (PA req) PA + copay	1–2 weeks
⌁ Remote patient monitoring (RPM) owner: RN / Case Manager / MD	Skilled services	Covered Part B RPM (CPT 99453/99454/99457/99458); ≥ 16 days of data per 30 days required	Covered (PA req) PA + program	Tiered formulary State-specific; coverage expanding	Covered (PA req) Varies by plan	Same week (enrollment)
◈ Behavioral health IOP (intensive outpatient) owner: Social Worker / Psychiatry	Behavioral health	Covered (PA req) Medicare IOP benefit since CY2024 final rule (~9–19 hrs/wk); physician certification	Covered (PA req) Carve-out vendor UM	Covered County BH / DMC-ODS for SUD; MHPAEA parity	Covered (PA req) Carve-out (Carelon / Magellan / Optum) UM	3–7 days (slot + auth)
◆ Behavioral health PHP (partial hospitalization) owner: Psychiatry / Social Worker	Behavioral health	Covered (PA req) Part B PHP; ≥ 20 hrs/wk; 42 CFR §410.43; physician certification required	Covered (PA req) Carve-out UM	Covered County BH; MHPAEA parity	Covered (PA req) Carve-out UM	2–5 days
❂ Caregiver training owner: RN / PT / OT / Case Manager	Caregiver support	Covered Caregiver Training Services reimbursable since CY2024 (CPT 96202/96203, 97550-97552)	Covered (PA req) PA + benefit varies	Covered (PA req) HCBS waiver / EPSDT	Tiered formulary Often bundled; standalone varies	Same admission (inpatient teaching)
☾ Caregiver respite owner: Social Worker / Case Manager	Caregiver support	Covered (PA req) Hospice respite benefit — up to 5 consecutive inpatient days; otherwise not a standard Medicare benefit	Covered Some MA supplemental respite benefit	Covered (PA req) HCBS waiver respite	Not covered Private pay / charity / AAA	Days to weeks (program capacity)
§ Legal aid (medical-legal partnership) owner: Social Worker	Social determinants	Not covered Not a medical benefit	Covered (PA req) Some MA plans fund MLP partnerships as SDOH	Covered (PA req) Some 1115 community-support / in-lieu-of services	Not covered Pro bono / charity	Days to weeks (intake capacity)
⚑ Immigration support owner: Social Worker / Community Health Worker	Social determinants	Not covered Not a medical benefit	Not covered Community partner referral	Covered (PA req) CA full-scope Medi-Cal regardless of status (2024 expansion) covers care; legal navigation via partners	Not covered Charity / community	Days to weeks
⚡ Utility assistance owner: Social Worker	Social determinants	Not covered Not a medical benefit	Covered (PA req) Some MA SDOH benefit	Covered (PA req) Some HCBS / community supports	Not covered LIHEAP / utility programs	Days (shut-off hold) to weeks (enrollment)
✪ Disability benefits navigation owner: Social Worker / Community Health Worker	Social determinants	Not covered Not a medical benefit	Covered (PA req) Some MA care-navigation	Covered (PA req) IHSS via county; Medi-Cal linked	Not covered SOAR / community navigators	Weeks to months (SSA timeline)
✺ Peer support owner: Social Worker / Peer Specialist	Behavioral health	Tiered formulary Limited; some peer services via BH benefit	Covered (PA req) Plan-specific	Covered CA Medi-Cal Peer Support Specialist benefit (2022); many states cover	Tiered formulary Varies; MHPAEA parity	Days (connection)

Medications · 8 categories

℞

Oral medications

New or modified prescriptions to fill before / at discharge.

Typical PA TAT

1–24h (CoverMyMeds real-time decision in 40% of cases)

Owners

Pharmacy, Pharm Tech

Triggers

New med added during admission
Dose change
Affordability concern flagged in intake

Workflow

1.Pharmacist runs reconciliation on DC-1 day
2.Engine pre-checks formulary tier + PA + pharmacy stock
3.PA drafted by AI agent, reviewed + submitted by pharmacist
4.Meds-to-beds delivery before transport leaves

Partner integrations

CoverMyMedsElectronic PA submission to PBM
SurescriptsePrescribing + formulary lookup
Local retail pharmaciesSame-day fill + meds-to-beds

Common denial reasons

Step therapy not documented

Formulary alternative available

Quantity limit exceeded

Diagnosis not on label

Routes that use this

homesnfalfhospice home

Watch-outPharmacy stock-out at patient's chosen retail; same-day fill is the leverage point — confirm by phone before discharge.

✦

Specialty pharmacy (biologics, oral oncology)

Limited-distribution drugs (Humira biosim, oral chemo, GLP-1, rare disease).

Typical PA TAT

24–72h (manufacturer hub + payer PA serial)

Owners

Pharmacy, Case Manager

Triggers

New biologic or oral chemo started inpatient
Rare disease maintenance
Plan-specific specialty pharmacy carve-out

Workflow

1.Identify specialty drug + plan-specific pharmacy
2.Drug-specific manufacturer hub enrollment
3.Patient-assistance program screen (foundation copay help)
4.Specialty pharmacy ships; patient acknowledges receipt

Partner integrations

Accredo / CVS Specialty / Optum SpecialtyDispensing
Manufacturer hubsEnrollment + adherence support
PAN / HealthWellCopay assistance foundations

Common denial reasons

Site-of-care restriction (must use specialty pharmacy)

Required clinical criteria not met

Copay accumulator / maximizer in effect

Routes that use this

home

Watch-outFirst fill can take 5–7 days. Bridge supply from inpatient pharmacy may be needed.

⚕

IV infusion at home (OPAT, biologics)

Home IV antibiotics, biologics, hydration via PICC or port + home-infusion vendor.

Typical PA TAT

24–72h

Owners

Pharmacy, Case Manager, MD

Triggers

OPAT antibiotic course required
Biologic infusion ongoing
Hydration / electrolyte support need

Workflow

1.Infusion order written + PICC confirmed
2.Home-infusion vendor matched (Coram, Option Care, BioPlus)
3.PA submitted to plan + specialty pharmacy
4.First nurse visit + caregiver training within 24–72h of DC

Partner integrations

Coram (CVS)Home infusion (BlueShield, Humana MA)
Option Care HealthHome infusion (commercial PPO)
Accredo / SpecialtySpecialty drug dispensing

Common denial reasons

Outpatient infusion suite preferred

Vendor not in-network

Duration not supported

Routes that use this

home

Watch-outRN visit capacity + plan-specific specialty pharmacy gating adds 24–72h delay.

◌

Total parenteral nutrition

Long-term nutrition via central line at home; weekly compounded cycles.

Typical PA TAT

3–7 days (LCD criteria documentation)

Owners

Pharmacy, Nutrition, Case Manager

Triggers

Gut failure
Short-bowel syndrome
Prolonged ileus

Workflow

1.GI / nutrition consult
2.Central access secured + tunneled
3.Vendor compounding scheduled (weekly cycles)
4.Patient + caregiver training (often 2–4 inpatient days)

Partner integrations

Coram / Option CareTPN compounding + delivery
BioScrip / NufactorSpecialty home infusion

Common denial reasons

LCD criteria not met (less than 90d)

Enteral feeding feasible

Vendor not contracted

Routes that use this

home

Watch-outTraining + vendor onboarding can add 2–4 inpatient days. Start day 1 of admit if gut failure suspected.

✻

Oncology supportive (anti-emetics, GCSF, growth factors)

Supportive cancer meds for chemo nadir + symptom control.

Typical PA TAT

24–72h

Owners

Oncology, Pharmacy, Case Manager

Triggers

Chemo cycle inpatient
Febrile neutropenia
Severe nausea / pain

Workflow

1.Oncology orders supportive meds
2.Specialty pharmacy + home infusion arranged
3.Patient assistance enrolled if needed

Partner integrations

Accredo / OnmarkOncology specialty pharmacy
CoramHome infusion (GCSF, IV anti-emetics)
Manufacturer PAPsPatient assistance for high-cost biologics

Common denial reasons

Indication off-label

Step therapy

Routes that use this

home

Watch-outChemo nadir timing matters; GCSF must reach patient day +1 to +3 of nadir.

✸

Palliative meds + symptom kit

Comfort pack (morphine, lorazepam, glycopyrrolate, haloperidol) for hospice.

Typical PA TAT

Same day (hospice benefit)

Owners

Hospice MD, Hospice RN, Pharmacy

Triggers

Hospice election
Active dying signs

Workflow

1.Hospice MD orders comfort pack
2.Hospice pharmacy delivers within 24h
3.Family + nurse trained on PRN dosing

Partner integrations

Hospice agency pharmacyComfort pack delivery

Common denial reasons

Hospice election not on file

Routes that use this

hospice homehospice ipu

Watch-outDEA constraints on opioid quantities; emergency refill plan critical.

✚

MAT (buprenorphine, methadone, naltrexone)

Bridge prescription + outpatient handoff for medications for opioid use disorder.

Typical PA TAT

Same day to 72h

Owners

Addiction Med, Social Worker, Pharmacy

Triggers

Opioid use disorder diagnosed
Overdose admission

Workflow

1.Inpatient induction (bupe X-waiver no longer required since 2023)
2.Bridge prescription (3–7 days) until outpatient slot
3.Warm handoff to outpatient MAT clinic
4.Naloxone kit at discharge

Partner integrations

Westside / Bridge ClinicOutpatient MAT
Methadone clinicsFederally regulated; daily dosing
Bridge MD networkTelehealth bridge

Common denial reasons

Bridge clinic capacity

Prior auth on long-acting naltrexone

Routes that use this

homeshelter respite

Watch-outPatients on MAT are higher overdose risk if treatment lapses — never discharge without warm handoff.

✿

Discharge vaccinations (flu, RSV, COVID, pneumo)

Catch-up vaccines before DC; reduces 30-day readmit for at-risk patients.

Typical PA TAT

Same day

Owners

RN, Pharmacy

Triggers

Age ≥ 65
Chronic disease (CHF, COPD)
Immunocompromised

Workflow

1.RN reviews vaccine history
2.Pharmacy administers at bedside
3.VIS forms + ack

Partner integrations

State immunization registry (CAIR2)VIS record
Inpatient pharmacyBedside administration

Common denial reasons

Recent vaccination on file

Routes that use this

homesnfalf

Watch-outEasy win for readmit reduction; should be checklisted at DC.

Durable medical equipment · 12 categories

◔

Enteral feeding (G-tube / PEG / NJ)

Pump, formula, supplies + caregiver training for tube feeding.

Typical PA TAT

48–96h

Owners

Nutrition, Case Manager

Triggers

New PEG placement
Dysphagia
Long-term nutrition need

Workflow

1.GI tube placed; first feeds inpatient
2.Vendor + formula ordered (Liquid Hope, Jevity, Glucerna, Kate Farms)
3.Caregiver training (RN + dietitian)
4.HH RN follow-up first 2 weeks

Partner integrations

CCS Medical / EdgeparkEnteral DME shipping
Coram / Option CareEnteral nutrition home delivery

Common denial reasons

Functional GI tract present

Trial of oral diet not documented

Vendor not in-network

Routes that use this

homesnfltch ltac

Watch-outFormula stock-outs; caregiver training time can delay 1–2 days.

○

Home oxygen

Concentrator + portable tanks + CMN form 484 for chronic O₂ need.

Typical PA TAT

8–48h (vendor + payer concurrent)

Owners

Case Manager, RN

Triggers

Resting SpO₂ < 88% on RA
6-min walk test desaturation
Chronic lung disease

Workflow

1.MD documents qualifying SpO₂ + CMN form 484
2.Vendor matched (Lincare, Apria, Inogen) — primary + backup
3.Delivery + setup at home pre-DC
4.Patient + caregiver O₂ safety education

Partner integrations

LincareLargest national O₂ DME network
Apria HealthcareBackup vendor + faster ad-hoc
InogenPortable concentrator (active lifestyle)

Common denial reasons

Qualifying SpO₂ not documented

Vendor not in network

Existing equipment in 36-mo cap

Routes that use this

homehospice home

Watch-outWeekend delivery scarce — book by Thu AM for Mon DC. #1 DME delay driver in our census.

≋

CPAP / BiPAP

Sleep apnea / respiratory support — titration + adherence requirements.

Typical PA TAT

48–96h

Owners

Pulmonology, Case Manager

Triggers

Sleep study confirmed OSA
Hypercapnic respiratory failure
COPD with NIV requirement

Workflow

1.Titration study or in-lab settings
2.Vendor matched + adherence monitoring set
3.Mask fitting + education
4.90-day adherence check for continued coverage

Partner integrations

ResMed AirViewAdherence telemetry
Philips DreamMapperAdherence telemetry
Lincare / ApriaDispensing + titration

Common denial reasons

Sleep study not on file

Adherence threshold not met (continued)

Bilevel without trial of CPAP

Routes that use this

home

Watch-outCoverage CANCELS if 90-day adherence < 70%; CM should set follow-up to verify.

≡

Nebulizer + respiratory meds

Compressor + albuterol / budesonide for home respiratory.

Typical PA TAT

24–48h

Owners

RN, Case Manager

Triggers

COPD exacerbation
Asthma flare
RSV in pediatric

Workflow

1.MD prescribes neb + meds
2.Vendor delivers compressor + supplies
3.Patient + caregiver demo

Partner integrations

Edgepark / CCS MedicalDME shipping
CVS / WalgreensNeb medications

Common denial reasons

MDI trial not documented

Frequency excessive

Routes that use this

home

Watch-outInhaler trial usually required before nebulizer coverage.

♿

Mobility DME (walker, wheelchair, commode)

Walker, cane, wheelchair, transfer board, bedside commode.

Typical PA TAT

24–48h (manual walker often same-day)

Owners

OT, PT, Case Manager

Triggers

New mobility limitation
Fall risk
Stairs at home

Workflow

1.OT/PT recommends specific equipment
2.Vendor matched + delivery booked (often day-of-DC)
3.Caregiver trained on transfers + use

Partner integrations

Parachute HealthMulti-vendor DME ordering
Lincare / ApriaDirect delivery

Common denial reasons

Existing equipment in cap

Lower-cost alternative available

Power chair without thorough documentation

Routes that use this

homesnfirf aru

Watch-outPower wheelchair: 30–90 day wait + extensive documentation. Manual is fast.

≣

Hospital bed at home

Semi-electric hospital bed for medically necessary need.

Typical PA TAT

48–72h

Owners

Case Manager, OT

Triggers

Patient cannot transfer to flat bed
Wound care positioning
End-of-life setup

Workflow

1.MD documents medical necessity
2.Vendor delivers + assembles
3.Caregiver trained

Partner integrations

Lincare / ApriaBed delivery + setup

Common denial reasons

Mobility documented

Home setup not appropriate

Routes that use this

homehospice home

Watch-outHome setup logistics — confirm caregiver presence + adequate room.

◓

Negative-pressure wound therapy (NPWT VAC)

Wound VAC pump + canisters + drape kits.

Typical PA TAT

24–72h

Owners

Wound RN, Case Manager

Triggers

Complex surgical wound
Dehisced wound
Diabetic foot wound with depth

Workflow

1.Wound RN initiates VAC inpatient
2.Vendor matched (3M, Cardinal Health)
3.HH RN visits for dressing changes

Partner integrations

3M (Acelity KCI)VAC equipment + canisters
Cardinal Health PROBackup VAC vendor

Common denial reasons

Wound size not justifying VAC

Conservative therapy not tried

Routes that use this

homesnfltch ltac

Watch-outVAC equipment supply chain can delay 24–72h.

◊

Ostomy supplies + WOCN follow-up

Wafers, pouches, paste, deodorant + outpatient WOCN.

Typical PA TAT

24–72h

Owners

WOCN, RN, Case Manager

Triggers

New ostomy
Ostomy revision

Workflow

1.WOCN inpatient teaching (2–4 sessions)
2.Initial supply box on discharge
3.Outpatient WOCN follow-up + DME re-supply

Partner integrations

Edgepark / 180 MedicalMonthly supply shipping
Local WOCN clinicOutpatient follow-up

Common denial reasons

Quantity exceeds LCD limit

Routes that use this

homesnf

Watch-outCaregiver education time can be substantial — start day 1.

◐

Urinary supplies (catheter, leg bag)

Intermittent or indwelling catheter supplies.

Typical PA TAT

24–72h

Owners

RN, Case Manager

Triggers

Urinary retention
Neurogenic bladder
Post-prostatectomy

Workflow

1.Type confirmed (intermittent vs indwelling)
2.Vendor matched + monthly delivery scheduled
3.Patient / caregiver education

Partner integrations

180 Medical / EdgeparkMonthly catheter shipping

Common denial reasons

Quantity > LCD

Routes that use this

homesnf

Watch-outRecurring delivery setup matters; verify auto-ship.

◇

Tracheostomy supplies + RT follow-up

Trach tubes, suction supplies, inner cannulas, HME filters + caregiver training.

Typical PA TAT

48–72h

Owners

RT, Case Manager

Triggers

New tracheostomy
Trach in chronic patient

Workflow

1.RT inpatient training (caregivers + patient)
2.Vendor matched + monthly supply
3.Outpatient RT follow-up scheduled

Partner integrations

Edgepark / AeroflowTrach supply shipping

Common denial reasons

Quantity limits

Routes that use this

homeltch ltacsnf

Watch-outCaregiver training is substantial — often 3–5 days; emergency call plan must be set.

⊙

Diabetes supplies (CGM, strips, pens, lancets)

Continuous glucose monitor, test strips, lancets, insulin pen needles, glucagon.

Typical PA TAT

24–72h

Owners

Pharmacy, CDE, Case Manager

Triggers

New diabetes diagnosis
Insulin start
Severe hypoglycemia event

Workflow

1.CDE / pharmacy education + teach-back
2.Supplies ordered (CGM via DME, strips via pharmacy)
3.App / receiver setup demonstrated

Partner integrations

Dexcom / Abbott LibreCGM systems
Edgepark / Solara MedicalCGM DME supplier
CoverMyMedsPA submission for CGM + strips

Common denial reasons

Insulin therapy not documented (CGM)

Hypoglycemia not documented

Quantity > 100 strips/mo without insulin

Routes that use this

home

Watch-outCGM PA criteria are tight; insulin use must be documented. Glucagon should be in every DM1 patient's box.

♡

Cardiac monitoring (event monitor, ILR, CardioMEMS)

Outpatient cardiac telemetry / implanted monitors for arrhythmia or CHF.

Typical PA TAT

48–96h

Owners

Cardiology, Case Manager

Triggers

Syncope workup
AFib / arrhythmia surveillance
Advanced CHF (NYHA III–IV)

Workflow

1.Cardiology orders device
2.Vendor matched + shipped (event monitor) or planted (ILR / CardioMEMS)
3.Remote monitoring set up + cardiology clinic notified

Partner integrations

iRhythm ZioPatch event monitor
Medtronic CareLinkILR / CardioMEMS remote monitoring
Abbott Merlin.netICD / pacer remote monitoring

Common denial reasons

Symptoms not documented

Shorter device not tried

Routes that use this

home

Watch-outCardioMEMS requires implant procedure — schedule before DC if appropriate.

Social determinants · 7 categories

⌂

Home safety modifications

Grab bars, ramps, raised toilet seats, stairlift assessment.

Typical PA TAT

1–3 weeks (charity intake)

Owners

OT, Social Worker

Triggers

Fall history
New mobility limitation
Stairs at home + no alternative bedroom

Workflow

1.OT home safety eval
2.Recommendations prioritized + funding source identified
3.Charity / waiver / private install

Partner integrations

Rebuilding TogetherCharity home mods for low-income
Area Agency on AgingSenior-specific funding

Common denial reasons

Funding not available

Owner consent missing (renters)

Routes that use this

home

Watch-outSlow to obtain; CM can discharge with portable safety items (commode + grab bars) while permanent install is scheduled.

✿

Food + nutrition

Meals on Wheels, Mom's Meals, CHF-friendly meal programs, SNAP enrollment.

Typical PA TAT

2–5 days

Owners

Dietitian, Social Worker

Triggers

Food insecurity screen positive
Disease-specific diet

Workflow

1.SW + dietitian assess + match to program
2.SNAP enrollment if eligible
3.Meals delivered post-DC; adherence tracked in portal

Partner integrations

Mom's MealsMA-contracted 14d post-DC meals
Project Open HandCharity meals
211 Bay AreaSNAP enrollment navigator

Common denial reasons

Plan benefit exhausted

Geography limit

Routes that use this

homealfhospice home

Watch-outVolume limits + delivery window; confirm enrollment before discharge.

⌂

Housing + SDOH supports

Shelter, respite, rental assistance, utility help, legal aid, immigration.

Typical PA TAT

Days to weeks (community capacity)

Owners

Social Worker, Community Health Worker

Triggers

Homeless or housing-insecure
Utility shut-off threat
Legal / immigration crisis

Workflow

1.SW screens (PRAPARE / AHC tool)
2.Match to community partner
3.Warm handoff with appointment

Partner integrations

Mercy HousingSubsidized rental
Bay Area Legal AidPro bono guardianship + immigration
211 Bay AreaUniversal SDOH navigator
PG&E LIHEAPUtility shut-off prevention

Common denial reasons

Waitlist

Documentation gaps

Routes that use this

homeshelter respite

Watch-outCommunity capacity + waitlists are real; build long-term relationships with partners.

Legal aid (medical-legal partnership)

Civil legal help — housing, benefits denials, guardianship, advance directives.

Typical PA TAT

Days to weeks (intake capacity)

Owners

Social Worker

Triggers

Eviction / housing legal issue
Benefits wrongly denied
Guardianship / conservatorship need

Workflow

1.SW screens legal need (I-HELP)
2.Refer to medical-legal partnership / legal aid
3.Warm handoff with intake appointment
4.Track resolution

Partner integrations

Bay Area Legal AidCivil legal services
Medical-Legal Partnership (hospital-based)Embedded legal help
Legal Aid SocietyBenefits + housing advocacy

Common denial reasons

Capacity / waitlist

Outside service scope

Routes that use this

homeshelter respite

Watch-outTime-sensitive matters (eviction, benefit-appeal deadlines) need an expedited referral.

⚑

Immigration support

Navigation for documentation, public-charge concerns, and immigrant-eligible benefits.

Typical PA TAT

Days to weeks

Owners

Social Worker, Community Health Worker

Triggers

Undocumented / mixed-status family
Public-charge fear blocking benefits
Need for immigration legal help

Workflow

1.SW screens immigration-related barriers
2.Refer to accredited immigration legal services
3.Connect to immigrant-eligible programs (e.g. full-scope Medi-Cal)
4.Warm handoff

Partner integrations

CLINIC / accredited immigration legal servicesLegal navigation
Catholic Charities immigrationApplication support
International Institute of the Bay AreaImmigrant services

Common denial reasons

Capacity

Case complexity beyond clinic scope

Routes that use this

homeshelter respite

Watch-outPublic-charge misinformation deters enrollment — reassure that emergency care + many programs are safe to use.

⚡

Utility assistance

Help preventing shut-off + funding for power-dependent equipment (O₂, CPAP, dialysis).

Typical PA TAT

Days (shut-off hold) to weeks (enrollment)

Owners

Social Worker

Triggers

Utility shut-off notice
Power-dependent DME at home (O₂, vent, CPAP)
Energy-insecurity screen positive

Workflow

1.SW screens energy insecurity
2.Enroll in LIHEAP / utility-discount programs
3.Medical-baseline allowance for power-dependent DME
4.Confirm continuity before discharge

Partner integrations

PG&E CARE/FERA + Medical BaselineDiscount + shut-off protection
LIHEAP (federal)Energy bill assistance
211 Bay AreaUtility-assistance navigator

Common denial reasons

Income above threshold

Documentation gaps

Routes that use this

home

Watch-outPower-dependent DME (O₂ / vent) → enroll Medical Baseline + shut-off protection BEFORE discharge.

✪

Disability benefits navigation

Help applying for SSDI / SSI / IHSS and disability-related income + services.

Typical PA TAT

Weeks to months (SSA timeline)

Owners

Social Worker, Community Health Worker

Triggers

New disabling condition
Loss of income / inability to work
Needs IHSS / in-home support

Workflow

1.SW screens disability + income need
2.SOAR-assisted SSDI / SSI application
3.IHSS / county referral
4.Track application + appeals

Partner integrations

SSA / SOAR-trained navigatorExpedited SSDI/SSI applications
County IHSS / Disability Rights CAIn-home support + advocacy
Independent Living Resource CenterDisability navigation

Common denial reasons

Initial SSDI/SSI denial (common — appeal)

Insufficient medical documentation

Routes that use this

homeshelter respite

Watch-outSSDI/SSI initial denials are common; SOAR-assisted applications approve faster — strong medical documentation is key.

Skilled services · 9 categories

✚

Wound care supplies + skilled visits

Complex dressings + weekly RN visits for skilled wound care.

Typical PA TAT

24–48h

Owners

Wound RN, Case Manager

Triggers

Surgical wound complications
Pressure injury
Diabetic ulcer

Workflow

1.Wound RN consult inpatient
2.Supply order + HH skilled visit scheduled
3.Patient + caregiver education on dressing changes

Partner integrations

VNA Bay Area / Sutter Home CareSkilled wound RN
Medline / EdgeparkWound supplies

Common denial reasons

Caregiver capable of dressing changes (skilled denied)

Frequency not supported

Routes that use this

homesnf

Watch-outSupply chain bottlenecks on specialty foam dressings.

≈

Outpatient dialysis (HD, PD, home)

In-center or home dialysis chair / training at discharge.

Typical PA TAT

24–72h (chair-limited)

Owners

Nephrology, Case Manager

Triggers

New ESRD
Transient AKI on CKD
Travel dialysis

Workflow

1.Nephrology consult + access plan
2.Chair secured (Fresenius, DaVita, US Renal)
3.Insurance confirmed; transport scheduled

Partner integrations

Fresenius Kidney CareIn-center HD network
DaVitaIn-center HD + home
US Renal CareIndependent network

Common denial reasons

Chair scarcity (regional)

Out-of-network shift

Routes that use this

homesnf

Watch-outTue/Thu PM chairs scarcest; book early. Transport must align with chair times.

✤

Mental health follow-up

Outpatient psychiatry, therapy, peer support, crisis line.

Typical PA TAT

3–7 days (slot-limited)

Owners

Social Worker, Psychiatry, Case Manager

Triggers

Acute depression / suicidality
Substance use diagnosis
Bridge from inpatient psych

Workflow

1.SW assessment + warm handoff
2.Outpatient slot secured
3.Safety plan + crisis resources at discharge

Partner integrations

Westside Community ServicesOutpatient BH
BetterHelp / TalkspaceTelehealth therapy
988 Crisis LineCrisis safety net

Common denial reasons

Out-of-network

Higher level of care needed first

Routes that use this

homeshelter respite

Watch-outSlot availability is regional + insurance-network limited. Crisis number must be in DC packet.

→

Transport home / to next setting

See Logistics library for full options. Surfaced as a need for completeness.

Typical PA TAT

24h (≥48h advance ideal)

Owners

Case Manager

Triggers

No family vehicle
Wheelchair-bound
Long-distance transfer

Workflow

1.See Logistics library
2.Booked by CM with vendor
3.Confirmed with patient + family in portal

Partner integrations

ModivCareMedicaid + MA NEMT broker
Uber HealthPre-credentialed rideshare
AMR / FalckAmbulance (BLS / ALS)

Common denial reasons

Lower level of transport possible

Out-of-area

Routes that use this

homesnfirf arultch ltac

Watch-outLead time + plan-specific vendor matter; book ≥24h ahead for SNF transfer.

✛

Skilled home health (RN / PT / OT visits)

Intermittent skilled nursing + therapy at home under a physician-certified plan of care.

Typical PA TAT

24–72h (start-of-care)

Owners

Case Manager, RN

Triggers

Homebound + skilled need (wound, IV, teaching, skilled observation)
New / changed meds requiring skilled monitoring
Post-acute PT/OT needs deliverable at home

Workflow

1.MD certifies homebound + skilled need (CMS-485 plan of care)
2.HH agency matched + accepts referral
3.Start of care within 48h of discharge
4.RN/PT/OT visits per POC; recertification at 60 days

Partner integrations

VNA Bay Area / Sutter Care at HomeSkilled HH delivery
Stanford Home CareHealth-system HH
Kindred at HomeNational HH network

Common denial reasons

Not homebound

Caregiver can provide care (skilled denied)

Visit frequency not supported

Routes that use this

home

Watch-outHomebound + skilled-need documentation is the gate; a Friday discharge risks a Monday start-of-care slip.

➶

Outpatient PT / OT

Post-acute physical / occupational therapy in clinic or via home health.

Typical PA TAT

3–7 days (scheduling-limited)

Owners

PT, OT, Case Manager

Triggers

Deconditioning / mobility deficit
Post-orthopedic or post-stroke rehab
ADL retraining need

Workflow

1.PT/OT evaluation + plan of care
2.Clinic or HH therapy scheduled
3.Progress tracked against functional goals
4.Re-authorization at visit cap

Partner integrations

Select Physical Therapy / ATIOutpatient rehab clinics
Stanford RehabilitationHealth-system outpatient therapy

Common denial reasons

Plateau / no functional progress

Visit cap reached

Maintenance therapy (non-skilled)

Routes that use this

homesnfirf aru

Watch-outKX-modifier threshold + medical-necessity documentation gate continued visits.

♥

Cardiac rehabilitation

Monitored exercise + risk-factor program after a qualifying cardiac event.

Typical PA TAT

1–2 weeks (program slot)

Owners

Cardiology, Case Manager

Triggers

Post-MI / PCI / CABG
Stable angina or valve repair
HFrEF EF ≤ 35% NYHA II–IV

Workflow

1.Cardiology referral + risk stratification
2.Enroll in CR program (≤ 36 sessions / 36 weeks)
3.Monitored exercise + secondary-prevention education
4.Intensive cardiac rehab (ICR) option for eligible programs

Partner integrations

Hospital-based CR programMonitored cardiac rehab
Sutter / Stanford cardiac rehabHealth-system CR
Pritikin ICRIntensive cardiac rehab

Common denial reasons

Qualifying diagnosis not documented

Session cap reached

Missed enrollment window

Routes that use this

home

Watch-outThe qualifying-diagnosis list is specific (NCD 20.10); enroll within weeks of the event.

⊛

Pulmonary rehabilitation

Supervised exercise + education for moderate-to-very-severe COPD / post-COVID.

Typical PA TAT

1–2 weeks

Owners

Pulmonology, Case Manager

Triggers

GOLD II–IV COPD
Recent COPD exacerbation / hospitalization
Post-COVID respiratory impairment

Workflow

1.Pulmonology referral + PFT documentation
2.Enroll in PR program (≤ 36 sessions)
3.Supervised exercise + inhaler / breathing education
4.Maintenance plan at completion

Partner integrations

Hospital-based PR programSupervised pulmonary rehab
Stanford / UCSF pulmonary rehabHealth-system PR

Common denial reasons

PFT severity not documented

Session cap reached

Routes that use this

home

Watch-outSpirometry severity (GOLD II–IV) must be on file before referral.

⌁

Remote patient monitoring (RPM)

Connected weight / BP / glucose / SpO₂ monitoring with clinician review for high-risk chronic disease.

Typical PA TAT

Same week (enrollment)

Owners

RN, Case Manager, MD

Triggers

CHF / COPD readmission risk
Uncontrolled hypertension or diabetes
Post-discharge transition monitoring

Workflow

1.Enroll patient + ship connected device
2.Capture ≥ 16 days of readings per 30 days
3.Clinician reviews + monthly management
4.Escalate on threshold breach

Partner integrations

Cadence / Optimize HealthRPM platform + monitoring
Health Recovery SolutionsRPM kits + telehealth
BodyTrace / connected devicesCellular monitoring devices

Common denial reasons

Fewer than 16 days of readings

Device not connected

No qualifying chronic condition

Routes that use this

home

Watch-outBilling requires ≥ 16 days of readings per 30 days — patient engagement is the failure point.

Education & teaching · 1 categories

✎

Disease + medication education

Plain-language teaching + caregiver coaching for chronic condition + new meds.

Typical PA TAT

Same day

Owners

RN, Pharmacy, AI Agent

Triggers

New chronic dx
High-risk medication added
LEP or low health literacy

Workflow

1.RN identifies education needs
2.Portal-translator agent re-renders at 6th-grade level
3.Patient + caregiver complete videos + ack
4.Teach-back at bedside before discharge

Partner integrations

HealthwiseExit / KramesStock education library
Anthropic Claude (via runAgent)Plain-language re-render

Routes that use this

homesnfirf aru

Watch-outLEP / low literacy — interpreter required + 6th-grade reading level adjustment.

Behavioral health · 3 categories

◈

Behavioral health IOP (intensive outpatient)

~9–19 hrs/week structured therapy — step-down from inpatient or step-up from outpatient.

Typical PA TAT

3–7 days (slot + auth)

Owners

Social Worker, Psychiatry

Triggers

Step-down from inpatient psych
SUD needing structure short of residential
Outpatient therapy insufficient

Workflow

1.BH assessment + level-of-care (ASAM / LOCUS)
2.IOP slot secured + authorization
3.3–5 days/week group + individual therapy
4.Step-down to routine outpatient

Partner integrations

County Behavioral HealthPublic IOP + SUD
Community IOP providersOutpatient intensive programs
Carve-out vendor (Optum / Magellan / Carelon)Authorization

Common denial reasons

Level-of-care criteria not met (ASAM)

Out-of-network

Lower level of care appropriate

Routes that use this

home

Watch-outThe carve-out vendor authorizes separately from medical — start the auth before discharge.

◆

Behavioral health PHP (partial hospitalization)

≥ 20 hrs/week day-hospital program — highest-intensity ambulatory psych / SUD care.

Typical PA TAT

2–5 days

Owners

Psychiatry, Social Worker

Triggers

Step-down from inpatient psych
Acute symptoms needing daily structure
Safety manageable without 24h care

Workflow

1.BH assessment + PHP level-of-care
2.PHP authorization + slot
3.5 days/week day program
4.Step-down to IOP / outpatient

Partner integrations

Hospital-based PHPDay-hospital program
County Behavioral HealthPublic PHP
Carve-out vendorAuthorization

Common denial reasons

Level-of-care criteria not met

Inpatient more appropriate

Out-of-network

Routes that use this

home

Watch-outPhysician certification + ≥ 20 hr/wk structure required; document medical necessity.

✺

Peer support

Certified peer specialists with lived experience — recovery, engagement, navigation.

Typical PA TAT

Days (connection)

Owners

Social Worker, Peer Specialist

Triggers

SUD / mental-health recovery
Low engagement / social isolation
Benefit from lived-experience support

Workflow

1.Identify peer-support fit
2.Connect to certified peer specialist / recovery community
3.Warm handoff
4.Ongoing peer engagement

Partner integrations

Certified Peer Support Specialists (county BH)Lived-experience support
Recovery community organizationsPeer recovery
NAMI / warmlinesPeer + family support

Common denial reasons

Not a covered benefit (some commercial)

No certified peer available

Routes that use this

homeshelter respite

Watch-outMedi-Cal covers certified peer specialists; commercial coverage is uneven — verify the benefit.

Caregiver support · 2 categories

❂

Caregiver training

Structured teaching for family / caregivers on wound, transfer, tube, med, or device care.

Typical PA TAT

Same admission (inpatient teaching)

Owners

RN, PT, OT, Case Manager

Triggers

New device / tube / wound requiring a caregiver
Functional dependence + family caregiver
High-risk medication regimen

Workflow

1.Identify caregiver + learning needs
2.RN / PT / OT structured training + teach-back
3.Competency verified before discharge
4.HH reinforcement first 2 weeks

Partner integrations

Inpatient RN / PT / OTBedside training + teach-back
HH agencyHome reinforcement
Disease-specific foundationsTeaching materials

Common denial reasons

Standalone CTS not recognized by plan

Caregiver unavailable

Routes that use this

homesnf

Watch-outCaregiver availability + teach-back competency is the real gate, not coverage — start day 1.

☾

Caregiver respite

Temporary relief care so a family caregiver can rest — in-home or short facility stay.

Typical PA TAT

Days to weeks (program capacity)

Owners

Social Worker, Case Manager

Triggers

Caregiver burnout / sole caregiver
High-dependence patient at home
Hospice family support need

Workflow

1.SW assesses caregiver strain
2.Match to respite funding (hospice / HCBS / AAA)
3.Schedule in-home or facility respite
4.Reassess caregiver capacity

Partner integrations

Hospice agencyInpatient respite (hospice benefit)
Area Agency on Aging (OAA Title III-E)National Family Caregiver Support respite
Adult day programsDaytime respite

Common denial reasons

Not hospice-enrolled (Medicare respite)

Waiver waitlist

Funding exhausted

Routes that use this

homehospice home

Watch-outOutside hospice / HCBS, respite is largely unfunded — AAA + adult day programs are the safety net.

⚙How this screen works

Needs library is the bridge between clinical reality and payer rules

Inputs

What this screen reads

Per-need clinical triggers from cockpit barriers + chart
Patient's verified payer plan (X12 271)
Partner-rule library per need category

Engine

What it computes

Maps need → payer coverage status (covered / PA / patient-pay / not covered)
Surfaces partner integration path (CoverMyMeds, Parachute, Coram, etc.)
Flags common denial reasons before submission
Cross-refs which route options need this

Outputs

What it writes / routes

Cockpit coverage matrix pre-populated per patient
PA drafting pipeline (AI drafts → human reviews → CoverMyMeds submit)
Patient-pay risk flagged to CM + caregiver

Refresh trigger

When it updates

Plan change (new payer effective date)
Formulary update via Surescripts
PA decision webhook

Partners involved:CoverMyMeds (Rx PA)Availity (medical PA)Surescripts (formulary)Coram / Option Care / Accredo (specialty + infusion)Parachute Health (DME aggregation)

Demo data · no PHI · mocked Epic + payer endpoints