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

Patient workflow

Carlos Rivera · COPD exacerbation (J44.1) · assigned pathway with step status
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Active pathway · HOMEhigh riskmatch 64%

Home + CHF discharge bundle

ACC/AHA HFrEF 2022 GDMT initiation + Coleman 4-pillar transition + RPM weights to drive 30-d readmission below the HRRP penalty threshold.

Matched on: disposition=HOME · services=HOME_DME+OUTPATIENT_PHARMACY

LACE+ 7 (MODERATE) + HOSPITAL 1 (LOW) → MODERATE. · bumped by: HRRP-tracked condition

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7 / 22 steps
7 done3 in progress11 blocked1 pending
Service stack
  • · Home Health
  • · Remote monitoring
  • · Home DME
  • · Outpatient pharmacy
  • · Outpatient PT / OT
Evidence basis
  • · ACC/AHA HFrEF Guideline 2022 §9.4
  • · Coleman CTI (Care Transitions Intervention)
  • · Project RED (Re-Engineered Discharge)
  • · HRRP §3025 ACA
  • · CMS RPM CPT 99453–99458
Outcome metrics
  • · HRRP 30-d CHF readmission (penalty avoidance)
  • · Coleman CTI 30-d rehospitalization ↓~30%
  • · MTM-1 medication reconciliation completion
  • · 7-d post-DC follow-up visit completion
Disposition reference
  • · UB-04 01 · Home / self-care

Pre-discharge

6 of 12 done
  1. #1T-3d·HospitalistmedicalBlocked
    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
  2. #2T-3d·HospitalistmedicationDone
    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
  3. #3T-2d·Pharmacycost coverageHITLIn progress
    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
  4. #4T-2d·Hospitalistcost coverageIn progress
    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
  5. #5T-2d·Case ManagerresourcesHITLDone
    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
  6. #6T-2d·Case ManagerresourcesHITLDone
    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
  7. #7T-2d·Case ManagerresourcesDone
    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
  8. #8T-1d·PharmacymedicationDone
    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
  9. #9T-1d·RNpatient agreementBlocked
    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
  10. #10T-1d·Case Managerpatient agreementBlocked
    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
  11. #11T-1d·Patient / Caregiverpatient agreementBlocked
    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
  12. #20T-2d·Social WorkerfunctionalDone
    Cognitive + activation screen — Mini-Cog + PAM-13. If Mini-Cog <3 or PAM-13 level <3, assign Coleman 'transition coach' for 30-d post-DC.

    Cognitive impairment + low activation are the strongest non-clinical predictors of readmission. Coleman trial showed largest benefit in this subgroup.

    Coleman et al. Arch Intern Med 2006 + Hibbard PAM-13·Evidence: Mini-Cog + PAM-13 scores in EHR; coach assignment if triggered

Day of discharge

1 of 3 done
  1. #12Day of DC·PharmacymedicationDone
    Meds-to-beds delivery — all GDMT scripts dispensed bedside before transport.

    Patient leaving without meds in hand = ED return within 7d in ~12% of CHF discharges.

    Project RED Component 6 (medications-to-bed)·Evidence: Meds-to-beds delivery signature
  2. #13Day of DC·RNmedicalBlocked
    Final pre-discharge vitals + weight; record baseline for RPM trending.

    RPM weight trending needs a verified baseline at discharge — otherwise the first home reading reads as a swing of unknown direction.

    AHA Scientific Statement on Remote Monitoring in HF·Evidence: Discharge vitals + weight in EHR
  3. #14Day of DC·Case Managercost coverageIn progress
    Write UB-04 Patient Discharge Status Code 01 (Home) to encounter; close all open referral loops.

    Encounter billing closes once UB-04 is set. Open referral loops = audit risk.

    NUBC UB-04 Patient Discharge Status Code list·Evidence: UB-04 01 on encounter

Post-discharge

0 of 7 done
  1. #15T+2d·VendormedicalBlocked
    Home Health start-of-care RN visit; verify med adherence, weight today, edema, dyspnea, fall safety.

    SOC visit ≤48h is a CMS HH condition of participation. Catches early decompensation.

    42 CFR §484.55 (HH comprehensive assessment)·Evidence: HH SOC OASIS assessment in EHR
  2. #16T+3d·VendormedicalHITLBlocked
    RPM data review — flag any weight gain ≥2 lb/24h or ≥5 lb/week; escalate to HF clinic via Voalte.

    First 72h post-DC is the highest-risk window for fluid re-accumulation.

    ACC/AHA HFrEF 2022 §9.4 + CMS RPM threshold guidance·Evidence: RPM dashboard review note
  3. #17T+7d·PCP / Follow-up MDmedicalBlocked
    Transition-of-care visit — review hospital course, titrate GDMT, repeat BMP + BNP, reconcile meds, confirm RPM adherence. Bill TCM CPT 99495 (or 99496 if high complexity within 7d).

    Coleman Pillar 3 + HRRP-tracked metric. 7-d visit is the highest-leverage post-DC touchpoint.

    Coleman CTI Pillar 3 + CPT 99495/99496·Evidence: TCM visit note with billed CPT 99495/99496
  4. #18T+1d·AI Agentpatient agreementHITLBlocked
    Day-1 post-DC Twilio SMS check-in: 'How are you feeling? Did you weigh yourself today? What was your weight?' Reply triages to RN if symptoms or weight gain.

    Day-1 SMS check-ins catch 25–40% of impending readmissions before symptoms peak (Naylor TCM analog).

    Naylor TCM (Health Affairs 2011) + AHRQ Care Transitions Resource·Evidence: SMS thread + patient response captured in EHR
  5. #19T+14d·RNmedicalBlocked
    14-day phone follow-up — assess GDMT titration tolerance, K+ / Cr labs if MRA started, social barriers, RPM adherence.

    Naylor TCM 90-day APRN-led bundle; 14-d check is the second highest-yield touchpoint.

    Naylor TCM (JAMA 1999)·Evidence: RN phone note
  6. #21T+21d·RNmedicalBlocked
    21-day APRN-led home visit — full Naylor TCM bundle: meds, function, social, GDMT titration progress, repeat BNP if clinically indicated.

    Naylor's 90-d bundle showed 30% readmit reduction; 21-d visit is the keystone touchpoint.

    Naylor et al. JAMA 1999 + Health Affairs 2011·Evidence: Naylor TCM 21-d visit note
  7. #22T+30d·Case ManagerPending
    30-d readmission gate — pull encounter record; if readmit occurred, kick off root-cause review and update LACE+ for the next admission.

    HRRP penalty is calculated on 30-d all-cause unplanned readmissions; root-causing each one improves the next pathway.

    HRRP §3025 ACA + CMS Hospital Compare methodology·Evidence: 30-d readmission review note
Demo data · no PHI · mocked Epic + payer endpoints