03 — Value stream · VS-540
Intake-to-Discharge
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.
- Post-Acute Episode
- Referral-to-Discharge
- Referral-to-Cash
- 01
Take Referral
VS-540.10Receive the referral with orders and history, check eligibility for the setting and confirm coverage.
- 02
Authorize & Admit
VS-540.20Obtain 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.
- 03
Assess
VS-540.30Complete the standardized admission assessment and submit it on time.
- 04
Plan & Equip
VS-540.40Agree the plan of care, schedule visits or services and deliver any home medical equipment.
- 05
Deliver Care
VS-540.50Deliver visits and services, document them at the point of care and reassess when the patient's condition changes.
- 06
Bill
VS-540.60Bill each home health period, skilled nursing month and hospice month as it closes, while care continues, and submit the claims.
- 07
Discharge & Report
VS-540.70Give 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.