{"version":"0.39.0","built_at":"2026-10-24T22:38:52.737Z","license":"CC BY 4.0 © Mike Reams","canonical":"https://catalog.mikereams.com","value_stream":{"id":"VS-540","name":"Intake-to-Discharge","industries":["healthcare"],"description":"Take a referral for home health, skilled nursing or hospice care, confirm the patient qualifies and is covered, admit and assess the patient, plan and deliver care in the home or the facility with the equipment it needs, bill under the setting's payment rules, and discharge or transfer the patient with a handoff. Hospital stays are Admit-to-Discharge.","outcome":"Each patient starts care promptly in the right setting, is assessed and cared for as planned, is paid for under the setting's rules, and leaves with a handoff the next caregiver can act on.","trigger":"A hospital, physician or family refers a patient for home health, skilled nursing or hospice care.","aliases":["Post-Acute Episode","Referral-to-Discharge","Referral-to-Cash"],"stages":[{"id":"VS-540.10","order":1,"name":"Take Referral","description":"Receive the referral with orders and history, check eligibility for the setting and confirm coverage.","capability_ids":["BC-1890.10","BC-1890.20","BC-1890.30","BC-1810.30"],"events":[]},{"id":"VS-540.20","order":2,"name":"Authorize & Admit","description":"Obtain any payer authorization, admit the patient or start home health care, or record the hospice election, and file the notice of admission or election within five days.","capability_ids":["BC-1810.40","BC-1890.10","BC-1890.20","BC-1890.30","BC-1890.60"],"events":[]},{"id":"VS-540.30","order":3,"name":"Assess","description":"Complete the standardized admission assessment and submit it on time.","capability_ids":["BC-1890.40"],"events":[]},{"id":"VS-540.40","order":4,"name":"Plan & Equip","description":"Agree the plan of care, schedule visits or services and deliver any home medical equipment.","capability_ids":["BC-1890.10","BC-1890.20","BC-1890.30","BC-1890.50"],"events":[]},{"id":"VS-540.50","order":5,"name":"Deliver Care","description":"Deliver visits and services, document them at the point of care and reassess when the patient's condition changes.","capability_ids":["BC-1890.10","BC-1890.20","BC-1890.30","BC-1890.40"],"events":[]},{"id":"VS-540.60","order":6,"name":"Bill","description":"Bill each home health period, skilled nursing month and hospice month as it closes, while care continues, and submit the claims.","capability_ids":["BC-1890.60","BC-1840.30","BC-1840.40"],"events":[]},{"id":"VS-540.70","order":7,"name":"Discharge & Report","description":"Give any required notice that covered services are ending, discharge or transfer the patient with a handoff the next caregiver can act on, complete the discharge assessment and report the setting's quality measures.","capability_ids":["BC-1890.10","BC-1890.20","BC-1890.30","BC-1890.40","BC-1890.60","BC-1850.10"],"events":[]}]}}