#1T-3d·Hospitalistmedicalgatingstd
Confirm euvolemic target reached — weight stable ≥24h, BNP/NT-proBNP trending down, no orthopnea or rest dyspnea.
Premature discharge before euvolemia is the single biggest driver of 30-d CHF readmission. ACC/AHA §9.4.
ACC/AHA HFrEF Guideline 2022 §9.4·Evidence: Hospitalist 'medically ready' attestation note·Routes via epic_writeback
#2T-3d·Hospitalistmedicationstd
Initiate / continue 4-pillar GDMT (ARNI or ACE-I/ARB · evidence-based BB · MRA · SGLT2 inhibitor) — start at hospital, titrate as outpatient.
Hospital is the highest-leverage moment to initiate GDMT. ACC/AHA Class I.
ACC/AHA HFrEF Guideline 2022 §7·Evidence: Discharge med list shows ≥3 of 4 GDMT classes·Routes via epic_writeback
#3T-2d·Pharmacycost coverageHITLgatingstd
Submit prior auth for ARNI (sacubitril/valsartan) and SGLT2i if formulary tier 3+; enroll in manufacturer assistance (Novartis Entresto Central, BI Jardiance Patient Assistance) in parallel.
ARNI + SGLT2i are the highest-impact GDMT additions and the most likely to be PA-denied. Parallel manufacturer-assist enrollment removes the affordability cliff.
CMS-0057-F (PA streamlining) + Novartis/BI PAP programs·Evidence: PA approval letter OR manufacturer-assist enrollment confirmation·Routes via covermymeds
#4T-2d·Hospitalistcost coveragegatingstd
F2F encounter note completed and signed — required for both Home Health (42 CFR §424.22) and Home DME scale/O₂ (42 CFR §410.38).
Missing F2F is the #1 reason HH start-of-care visits delay or get denied. One note covers both services.
42 CFR §424.22 + 42 CFR §410.38·Evidence: F2F note signed within HH eligibility window·Routes via epic_writeback
#5T-2d·Case ManagerresourcesHITLgatingstd
Place HH agency referral with CMS-485 plan of care elements; warm-handoff phone call to receiving HH RN.
Start-of-care visit must occur ≤48h after discharge — referral has to be in the agency's queue before the patient leaves the bed.
42 CFR §424.22 (HH conditions of participation)·Evidence: HH agency bed-hold / SOC-visit confirmation·Routes via naviguide
#6T-2d·Case ManagerresourcesHITLstd
Order RPM bundle — connected scale + BP cuff + pulse-ox; confirm vendor delivery window ≤72h post-DC.
Daily weight is the single most sensitive predictor of impending readmission. Without RPM, decompensation is invisible until ED.
CMS RPM CPT 99453/99454/99457/99458; AHA scientific statement on telemonitoring·Evidence: RPM vendor delivery confirmation·Routes via rpm_vendor
#7T-2d·Case Managerresourcesstd
Order Home DME (bathroom scale if not in RPM bundle; walker if mobility limited; O₂ concentrator if SpO₂ <88% on RA).
DME delivery is a frequent same-day-of-DC delay driver. Order ≥48h ahead.
42 CFR §410.38 (DMEPOS F2F + 6-month rule)·Evidence: DME supplier delivery slot booked·Routes via epic_writeback
#8T-1d·Pharmacymedicationgatingstd
Discharge medication reconciliation with teach-back — patient/caregiver verbalizes purpose, dose, timing, and warning signs for each of the 4 GDMT classes.
Coleman Pillar 1 (medication self-management). Reconciliation without teach-back fails — Project RED component 5.
Coleman CTI Pillar 1 + Project RED Component 5 + AHRQ Teach-Back Toolkit·Evidence: Pharmacist teach-back completion note + patient self-rated understanding·Routes via epic_writeback
#9T-1d·RNpatient agreementgatingstd
Deliver red-flag education with teach-back: daily weight gain ≥2 lb overnight or ≥5 lb in a week, increased dyspnea, orthopnea, swelling — call HF clinic, not 911 (unless severe).
Coleman Pillar 4 (red-flag knowledge). Patients who can name their warning signs have ~25% lower 30-d readmit.
Coleman CTI Pillar 4 + AHA Get With The Guidelines HF·Evidence: RN red-flag teach-back note + patient verbalized 3 warning signs·Routes via epic_mychart
#10T-1d·Case Managerpatient agreementgatingstd
Book 7-day post-DC transition-of-care visit with cardiology / HF clinic OR PCP; confirm appointment in patient's calendar + portal.
Coleman Pillar 3 (follow-up). HRRP-tracked: 7-d follow-up reduces 30-d readmit by ~20%. Bills as CPT 99495/99496.
Coleman CTI Pillar 3 + CPT TCM 99495/99496 (CMS)·Evidence: Appointment confirmed within 7d in EHR + portal·Routes via epic_mychart
#11T-1d·Patient / Caregiverpatient agreementstd
Confirm preferred pharmacy + delivery address + caregiver phone in MyChart preference form; review the After-Visit Summary with case manager.
Coleman Pillar 2 (dynamic PHR). Family decision-lag is the #1 cause of avoidable same-day delays at discharge.
Coleman CTI Pillar 2 + IDEAL Discharge Planning (AHRQ)·Evidence: Preference form submission timestamp·Routes via epic_mychart