Onboarding & Assessment

Onboarding and Assessment for Episode Connect

What is onboarding?

  • Identifying patients, using predictive analytics or manual processes

  • Introducing the bundled payment program to patients and delivering CMS-required materials.

  • Creating the patient’s Care Team and Assigning a Principal Accountable Practitioner (PAP)

  • Completing a Risk Assessment:

    • Predicts a patient’s risk for inpatient readmission

    • Assignes patients to risk levels that drive post-acute

      interventions and scheduled follow-up services

Episode Connect Onboarding and Assessment Tool Set

  • Predictive Analytics to identify patient

  • Automated patient profile creation and harvesting of their medical records into Episode Connect.

  • Module for creation of Care Teams with associated contact information

  • Risk Assessments and Functional Assessments – easy and quick initial risk assessment tool and customized supplemental assessments for functional, mental health, transportation and social needs

  • Care At the Right Location (CARL) Tool – assess critical discharge planning domains, including patient independence, living situation, caregiver availability and support, and specific skilled needs. Together, these factors help to recommend the safest and most appropriate next site of care.

    • An assessment of patient suitability for home or SNF care.

    • Patient and SNF matching

    • Determine length of stay and service needs

      in a post acute setting

    • A communications module assuring SNF, HHA or family

      receives complete instructions and physician orders. 

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