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

Discharge needs × insurance coverage

28 need categories × 4 payer types · with partner integrations + PA TAT + denial reasons

Discharge map Routes Logistics Needs × coverage Resource hub

Every patient leaves with a constellation of needs. OpenBed AI checks coverage for each need against the patient's specific plan in real-time, drafts the prior auth packet when required, surfaces partner integration paths, and flags common denial reasons before submission. Below: the matrix view, then per-need workflow detail grouped by category.

Coverage matrix

28 need categories × 4 payer types

Need	Cat.	Medicare FFS	Medicare Advantage	Medicaid	Commercial	PA TAT
℞ Oral medications owner: Pharmacy / Pharm Tech	Medications	Tiered formulary Part D plan-specific tiering; PA + step therapy common	Tiered formulary MAPD plan tiering; PA + step therapy	Covered (PA req) State preferred drug list; PA on non-preferred	Tiered formulary Plan formulary; PBM rules	1–24h (CoverMyMeds real-time decision in 40% of cases)
✦ Specialty pharmacy (biologics, oral oncology) owner: Pharmacy / Case Manager	Medications	Tiered formulary Part D specialty tier (Tier 5/6); high coinsurance	Tiered formulary MAPD specialty tier + PA	Covered (PA req) Step + PA + quantity limits	Covered (PA req) Carve-out to Accredo, CVS Specialty, Optum Specialty	24–72h (manufacturer hub + payer PA serial)
⚕ IV infusion at home (OPAT, biologics) owner: Pharmacy / Case Manager / MD	Medications	Covered (PA req) Part B for drugs + DME pump; Part D for some self-administered	Covered (PA req) PA + benefit varies	Covered (PA req) State PA; specialty pharmacy carve-out	Covered (PA req) Specialty pharmacy carve-out + PA	24–72h
◌ Total parenteral nutrition owner: Pharmacy / Nutrition / Case Manager	Medications	Covered (PA req) Part B + LCD criteria (90+ days gut failure documented)	Covered (PA req) PA + necessity review	Covered (PA req) State PA	Covered (PA req) Specialty pharmacy + PA	3–7 days (LCD criteria documentation)
◔ Enteral feeding (G-tube / PEG / NJ) owner: Nutrition / Case Manager	Durable medical equipment	Covered (PA req) Part B enteral nutrition + pump + supplies (LCD L33783)	Covered (PA req) PA + LCD-equivalent	Covered (PA req) State PA	Covered (PA req) PA + tier	48–96h
○ Home oxygen owner: Case Manager / RN	Durable medical equipment	Covered (PA req) Part B DMEPOS; 36-mo capped rental; LCD L33797	Covered (PA req) PA + plan-specific vendors	Covered (PA req) State PA + LCD-equivalent	Covered (PA req) PA + in-network vendor	8–48h (vendor + payer concurrent)
≋ CPAP / BiPAP owner: Pulmonology / Case Manager	Durable medical equipment	Covered (PA req) Part B; 90-day compliance requirement (4h/night ≥ 70%)	Covered (PA req) PA + adherence	Covered (PA req) State PA	Covered (PA req) PA + adherence	48–96h
≡ Nebulizer + respiratory meds owner: RN / Case Manager	Durable medical equipment	Covered Part B DMEPOS + meds	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA + tier	24–48h
♿ Mobility DME (walker, wheelchair, commode) owner: OT / PT / Case Manager	Durable medical equipment	Covered (PA req) Part B DMEPOS; HCPCS-coded; 20% coinsurance	Covered (PA req) PA + in-network DME	Covered (PA req) State PA	Covered (PA req) PA + tier	24–48h (manual walker often same-day)
≣ Hospital bed at home owner: Case Manager / OT	Durable medical equipment	Covered (PA req) Part B DMEPOS LCD; necessity documented	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) PA + tier	48–72h
⌂ Home safety modifications owner: OT / Social Worker	Social determinants	Not covered Not Medicare benefit	Covered SDOH benefit in some MA plans (Humana, Aetna)	Covered (PA req) Some HCBS waivers fund environmental mods	Not covered Charity / private pay	1–3 weeks (charity intake)
✚ Wound care supplies + skilled visits owner: Wound RN / Case Manager	Skilled services	Covered HH benefit + DMEPOS supplies under Part B	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) PA + tier	24–48h
◓ Negative-pressure wound therapy (NPWT VAC) owner: Wound RN / Case Manager	Durable medical equipment	Covered (PA req) Part B + LCD; medical necessity	Covered (PA req) PA + necessity	Covered (PA req) State PA	Covered (PA req) PA + tier	24–72h
◊ Ostomy supplies + WOCN follow-up owner: WOCN / RN / Case Manager	Durable medical equipment	Covered Part B DMEPOS; quantity limits per LCD	Covered (PA req) PA	Covered State coverage with limits	Covered (PA req) PA + tier	24–72h
◐ Urinary supplies (catheter, leg bag) owner: RN / Case Manager	Durable medical equipment	Covered Part B; monthly quantities per LCD	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA	24–72h
◇ Tracheostomy supplies + RT follow-up owner: RT / Case Manager	Durable medical equipment	Covered Part B DMEPOS	Covered (PA req) PA	Covered State coverage	Covered (PA req) PA + tier	48–72h
⊙ Diabetes supplies (CGM, strips, pens, lancets) owner: Pharmacy / CDE / Case Manager	Durable medical equipment	Covered (PA req) Part B CGM (qualifying criteria); Part D for strips/needles	Covered (PA req) PA + tier	Covered State coverage with PA on CGM	Covered (PA req) PA + tier	24–72h
♡ Cardiac monitoring (event monitor, ILR, CardioMEMS) owner: Cardiology / Case Manager	Durable medical equipment	Covered (PA req) Part B + LCD criteria	Covered (PA req) PA + necessity	Covered (PA req) State PA	Covered (PA req) PA + tier	48–96h
≈ Outpatient dialysis (HD, PD, home) owner: Nephrology / Case Manager	Skilled services	Covered Part B ESRD benefit (immediate eligibility)	Covered (PA req) PA + in-network	Covered (PA req) State PA	Covered (PA req) PA + 30-mo coordination then Medicare	24–72h (chair-limited)
✻ Oncology supportive (anti-emetics, GCSF, growth factors) owner: Oncology / Pharmacy / Case Manager	Medications	Covered (PA req) Part B for infused; Part D oral	Covered (PA req) PA	Covered (PA req) State PA	Covered (PA req) Specialty pharmacy + PA	24–72h
✸ Palliative meds + symptom kit owner: Hospice MD / Hospice RN / Pharmacy	Medications	Covered Hospice benefit covers meds	Covered Carved back to Medicare hospice	Covered Hospice benefit	Covered Most plans cover hospice	Same day (hospice benefit)
✚ MAT (buprenorphine, methadone, naltrexone) owner: Addiction Med / Social Worker / Pharmacy	Medications	Covered Part D + Part B for office-based	Covered (PA req) PA	Covered Federal mandate covers MOUD	Covered MHPAEA parity	Same day to 72h
✤ Mental health follow-up owner: Social Worker / Psychiatry / Case Manager	Skilled services	Covered Part B; MHPAEA parity	Covered (PA req) PA + network	Covered Behavioral health carve-out per state	Covered MHPAEA parity	3–7 days (slot-limited)
✿ Discharge vaccinations (flu, RSV, COVID, pneumo) owner: RN / Pharmacy	Medications	Covered Part B + Part D (varies by vaccine)	Covered Plan covered	Covered State VFC program	Covered ACA preventive	Same day
✎ Disease + medication education owner: RN / Pharmacy / AI Agent	Education & teaching	Covered Bundled into DRG	Covered Bundled	Covered Bundled	Covered Bundled	Same day
→ Transport home / to next setting owner: Case Manager	Skilled services	Patient pay NEMT not routinely covered	Covered (PA req) Supplemental NEMT benefit (rides/year)	Covered (PA req) NEMT broker (state)	Patient pay Generally patient-pay	24h (≥48h advance ideal)
✿ Food + nutrition owner: Dietitian / Social Worker	Social determinants	Not covered Not standard Medicare	Covered Many MA plans cover post-DC meals (14d) as SDOH benefit	Covered (PA req) Some HCBS waivers	Not covered Charity-funded	2–5 days
⌂ Housing + SDOH supports owner: Social Worker / Community Health Worker	Social determinants	Not covered Not Medicare scope	Covered (PA req) Some MA plans fund SDOH partnerships	Covered (PA req) 1115 waivers; in-lieu-of services in select states	Not covered Charity	Days to weeks (community capacity)

Medications · 8 categories

℞

Oral medications

New or modified prescriptions to fill before / at discharge.

Typical PA TAT

1–24h (CoverMyMeds real-time decision in 40% of cases)

Owners

Pharmacy, Pharm Tech

Triggers

New med added during admission
Dose change
Affordability concern flagged in intake

Workflow

1.Pharmacist runs reconciliation on DC-1 day
2.Engine pre-checks formulary tier + PA + pharmacy stock
3.PA drafted by AI agent, reviewed + submitted by pharmacist
4.Meds-to-beds delivery before transport leaves

Partner integrations

CoverMyMedsElectronic PA submission to PBM
SurescriptsePrescribing + formulary lookup
Local retail pharmaciesSame-day fill + meds-to-beds

Common denial reasons

Step therapy not documented

Formulary alternative available

Quantity limit exceeded

Diagnosis not on label

Routes that use this

homehome with hhsnfalfhospice home

Watch-outPharmacy stock-out at patient's chosen retail; same-day fill is the leverage point — confirm by phone before discharge.

✦

Specialty pharmacy (biologics, oral oncology)

Limited-distribution drugs (Humira biosim, oral chemo, GLP-1, rare disease).

Typical PA TAT

24–72h (manufacturer hub + payer PA serial)

Owners

Pharmacy, Case Manager

Triggers

New biologic or oral chemo started inpatient
Rare disease maintenance
Plan-specific specialty pharmacy carve-out

Workflow

1.Identify specialty drug + plan-specific pharmacy
2.Drug-specific manufacturer hub enrollment
3.Patient-assistance program screen (foundation copay help)
4.Specialty pharmacy ships; patient acknowledges receipt

Partner integrations

Accredo / CVS Specialty / Optum SpecialtyDispensing
Manufacturer hubsEnrollment + adherence support
PAN / HealthWellCopay assistance foundations

Common denial reasons

Site-of-care restriction (must use specialty pharmacy)

Required clinical criteria not met

Copay accumulator / maximizer in effect

Routes that use this

homehome with hh

Watch-outFirst fill can take 5–7 days. Bridge supply from inpatient pharmacy may be needed.

⚕

IV infusion at home (OPAT, biologics)

Home IV antibiotics, biologics, hydration via PICC or port + home-infusion vendor.

Typical PA TAT

24–72h

Owners

Pharmacy, Case Manager, MD

Triggers

OPAT antibiotic course required
Biologic infusion ongoing
Hydration / electrolyte support need

Workflow

1.Infusion order written + PICC confirmed
2.Home-infusion vendor matched (Coram, Option Care, BioPlus)
3.PA submitted to plan + specialty pharmacy
4.First nurse visit + caregiver training within 24–72h of DC

Partner integrations

Coram (CVS)Home infusion (BlueShield, Humana MA)
Option Care HealthHome infusion (commercial PPO)
Accredo / SpecialtySpecialty drug dispensing

Common denial reasons

Outpatient infusion suite preferred

Vendor not in-network

Duration not supported

Routes that use this

home with infusionhome with hh

Watch-outRN visit capacity + plan-specific specialty pharmacy gating adds 24–72h delay.

◌

Total parenteral nutrition

Long-term nutrition via central line at home; weekly compounded cycles.

Typical PA TAT

3–7 days (LCD criteria documentation)

Owners

Pharmacy, Nutrition, Case Manager

Triggers

Gut failure
Short-bowel syndrome
Prolonged ileus

Workflow

1.GI / nutrition consult
2.Central access secured + tunneled
3.Vendor compounding scheduled (weekly cycles)
4.Patient + caregiver training (often 2–4 inpatient days)

Partner integrations

Coram / Option CareTPN compounding + delivery
BioScrip / NufactorSpecialty home infusion

Common denial reasons

LCD criteria not met (less than 90d)

Enteral feeding feasible

Vendor not contracted

Routes that use this

home with infusion

Watch-outTraining + vendor onboarding can add 2–4 inpatient days. Start day 1 of admit if gut failure suspected.

✻

Oncology supportive (anti-emetics, GCSF, growth factors)

Supportive cancer meds for chemo nadir + symptom control.

Typical PA TAT

24–72h

Owners

Oncology, Pharmacy, Case Manager

Triggers

Chemo cycle inpatient
Febrile neutropenia
Severe nausea / pain

Workflow

1.Oncology orders supportive meds
2.Specialty pharmacy + home infusion arranged
3.Patient assistance enrolled if needed

Partner integrations

Accredo / OnmarkOncology specialty pharmacy
CoramHome infusion (GCSF, IV anti-emetics)
Manufacturer PAPsPatient assistance for high-cost biologics

Common denial reasons

Indication off-label

Step therapy

Routes that use this

homehome with hhhome with infusion

Watch-outChemo nadir timing matters; GCSF must reach patient day +1 to +3 of nadir.

✸

Palliative meds + symptom kit

Comfort pack (morphine, lorazepam, glycopyrrolate, haloperidol) for hospice.

Typical PA TAT

Same day (hospice benefit)

Owners

Hospice MD, Hospice RN, Pharmacy

Triggers

Hospice election
Active dying signs

Workflow

1.Hospice MD orders comfort pack
2.Hospice pharmacy delivers within 24h
3.Family + nurse trained on PRN dosing

Partner integrations

Hospice agency pharmacyComfort pack delivery

Common denial reasons

Hospice election not on file

Routes that use this

hospice homehospice ipu

Watch-outDEA constraints on opioid quantities; emergency refill plan critical.

✚

MAT (buprenorphine, methadone, naltrexone)

Bridge prescription + outpatient handoff for medications for opioid use disorder.

Typical PA TAT

Same day to 72h

Owners

Addiction Med, Social Worker, Pharmacy

Triggers

Opioid use disorder diagnosed
Overdose admission

Workflow

1.Inpatient induction (bupe X-waiver no longer required since 2023)
2.Bridge prescription (3–7 days) until outpatient slot
3.Warm handoff to outpatient MAT clinic
4.Naloxone kit at discharge

Partner integrations

Westside / Bridge ClinicOutpatient MAT
Methadone clinicsFederally regulated; daily dosing
Bridge MD networkTelehealth bridge

Common denial reasons

Bridge clinic capacity

Prior auth on long-acting naltrexone

Routes that use this

homehome with hhshelter respite

Watch-outPatients on MAT are higher overdose risk if treatment lapses — never discharge without warm handoff.

✿

Discharge vaccinations (flu, RSV, COVID, pneumo)

Catch-up vaccines before DC; reduces 30-day readmit for at-risk patients.

Typical PA TAT

Same day

Owners

RN, Pharmacy

Triggers

Age ≥ 65
Chronic disease (CHF, COPD)
Immunocompromised

Workflow

1.RN reviews vaccine history
2.Pharmacy administers at bedside
3.VIS forms + ack

Partner integrations

State immunization registry (CAIR2)VIS record
Inpatient pharmacyBedside administration

Common denial reasons

Recent vaccination on file

Routes that use this

homehome with hhsnfalf

Watch-outEasy win for readmit reduction; should be checklisted at DC.

Durable medical equipment · 12 categories

◔

Enteral feeding (G-tube / PEG / NJ)

Pump, formula, supplies + caregiver training for tube feeding.

Typical PA TAT

48–96h

Owners

Nutrition, Case Manager

Triggers

New PEG placement
Dysphagia
Long-term nutrition need

Workflow

1.GI tube placed; first feeds inpatient
2.Vendor + formula ordered (Liquid Hope, Jevity, Glucerna, Kate Farms)
3.Caregiver training (RN + dietitian)
4.HH RN follow-up first 2 weeks

Partner integrations

CCS Medical / EdgeparkEnteral DME shipping
Coram / Option CareEnteral nutrition home delivery

Common denial reasons

Functional GI tract present

Trial of oral diet not documented

Vendor not in-network

Routes that use this

homehome with hhsnfltac

Watch-outFormula stock-outs; caregiver training time can delay 1–2 days.

○

Home oxygen

Concentrator + portable tanks + CMN form 484 for chronic O₂ need.

Typical PA TAT

8–48h (vendor + payer concurrent)

Owners

Case Manager, RN

Triggers

Resting SpO₂ < 88% on RA
6-min walk test desaturation
Chronic lung disease

Workflow

1.MD documents qualifying SpO₂ + CMN form 484
2.Vendor matched (Lincare, Apria, Inogen) — primary + backup
3.Delivery + setup at home pre-DC
4.Patient + caregiver O₂ safety education

Partner integrations

LincareLargest national O₂ DME network
Apria HealthcareBackup vendor + faster ad-hoc
InogenPortable concentrator (active lifestyle)

Common denial reasons

Qualifying SpO₂ not documented

Vendor not in network

Existing equipment in 36-mo cap

Routes that use this

homehome with hhhospice home

Watch-outWeekend delivery scarce — book by Thu AM for Mon DC. #1 DME delay driver in our census.

≋

CPAP / BiPAP

Sleep apnea / respiratory support — titration + adherence requirements.

Typical PA TAT

48–96h

Owners

Pulmonology, Case Manager

Triggers

Sleep study confirmed OSA
Hypercapnic respiratory failure
COPD with NIV requirement

Workflow

1.Titration study or in-lab settings
2.Vendor matched + adherence monitoring set
3.Mask fitting + education
4.90-day adherence check for continued coverage

Partner integrations

ResMed AirViewAdherence telemetry
Philips DreamMapperAdherence telemetry
Lincare / ApriaDispensing + titration

Common denial reasons

Sleep study not on file

Adherence threshold not met (continued)

Bilevel without trial of CPAP

Routes that use this

homehome with hh

Watch-outCoverage CANCELS if 90-day adherence < 70%; CM should set follow-up to verify.

≡

Nebulizer + respiratory meds

Compressor + albuterol / budesonide for home respiratory.

Typical PA TAT

24–48h

Owners

RN, Case Manager

Triggers

COPD exacerbation
Asthma flare
RSV in pediatric

Workflow

1.MD prescribes neb + meds
2.Vendor delivers compressor + supplies
3.Patient + caregiver demo

Partner integrations

Edgepark / CCS MedicalDME shipping
CVS / WalgreensNeb medications

Common denial reasons

MDI trial not documented

Frequency excessive

Routes that use this

homehome with hh

Watch-outInhaler trial usually required before nebulizer coverage.

♿

Mobility DME (walker, wheelchair, commode)

Walker, cane, wheelchair, transfer board, bedside commode.

Typical PA TAT

24–48h (manual walker often same-day)

Owners

OT, PT, Case Manager

Triggers

New mobility limitation
Fall risk
Stairs at home

Workflow

1.OT/PT recommends specific equipment
2.Vendor matched + delivery booked (often day-of-DC)
3.Caregiver trained on transfers + use

Partner integrations

Parachute HealthMulti-vendor DME ordering
Lincare / ApriaDirect delivery

Common denial reasons

Existing equipment in cap

Lower-cost alternative available

Power chair without thorough documentation

Routes that use this

homehome with hhsnfaru

Watch-outPower wheelchair: 30–90 day wait + extensive documentation. Manual is fast.

≣

Hospital bed at home

Semi-electric hospital bed for medically necessary need.

Typical PA TAT

48–72h

Owners

Case Manager, OT

Triggers

Patient cannot transfer to flat bed
Wound care positioning
End-of-life setup

Workflow

1.MD documents medical necessity
2.Vendor delivers + assembles
3.Caregiver trained

Partner integrations

Lincare / ApriaBed delivery + setup

Common denial reasons

Mobility documented

Home setup not appropriate

Routes that use this

home with hhhospice home

Watch-outHome setup logistics — confirm caregiver presence + adequate room.

◓

Negative-pressure wound therapy (NPWT VAC)

Wound VAC pump + canisters + drape kits.

Typical PA TAT

24–72h

Owners

Wound RN, Case Manager

Triggers

Complex surgical wound
Dehisced wound
Diabetic foot wound with depth

Workflow

1.Wound RN initiates VAC inpatient
2.Vendor matched (3M, Cardinal Health)
3.HH RN visits for dressing changes

Partner integrations

3M (Acelity KCI)VAC equipment + canisters
Cardinal Health PROBackup VAC vendor

Common denial reasons

Wound size not justifying VAC

Conservative therapy not tried

Routes that use this

home with hhsnfltac

Watch-outVAC equipment supply chain can delay 24–72h.

◊

Ostomy supplies + WOCN follow-up

Wafers, pouches, paste, deodorant + outpatient WOCN.

Typical PA TAT

24–72h

Owners

WOCN, RN, Case Manager

Triggers

New ostomy
Ostomy revision

Workflow

1.WOCN inpatient teaching (2–4 sessions)
2.Initial supply box on discharge
3.Outpatient WOCN follow-up + DME re-supply

Partner integrations

Edgepark / 180 MedicalMonthly supply shipping
Local WOCN clinicOutpatient follow-up

Common denial reasons

Quantity exceeds LCD limit

Routes that use this

homehome with hhsnf

Watch-outCaregiver education time can be substantial — start day 1.

◐

Urinary supplies (catheter, leg bag)

Intermittent or indwelling catheter supplies.

Typical PA TAT

24–72h

Owners

RN, Case Manager

Triggers

Urinary retention
Neurogenic bladder
Post-prostatectomy

Workflow

1.Type confirmed (intermittent vs indwelling)
2.Vendor matched + monthly delivery scheduled
3.Patient / caregiver education

Partner integrations

180 Medical / EdgeparkMonthly catheter shipping

Common denial reasons

Quantity > LCD

Routes that use this

homehome with hhsnf

Watch-outRecurring delivery setup matters; verify auto-ship.

◇

Tracheostomy supplies + RT follow-up

Trach tubes, suction supplies, inner cannulas, HME filters + caregiver training.

Typical PA TAT

48–72h

Owners

RT, Case Manager

Triggers

New tracheostomy
Trach in chronic patient

Workflow

1.RT inpatient training (caregivers + patient)
2.Vendor matched + monthly supply
3.Outpatient RT follow-up scheduled

Partner integrations

Edgepark / AeroflowTrach supply shipping

Common denial reasons

Quantity limits

Routes that use this

home with hhltacsnf

Watch-outCaregiver training is substantial — often 3–5 days; emergency call plan must be set.

⊙

Diabetes supplies (CGM, strips, pens, lancets)

Continuous glucose monitor, test strips, lancets, insulin pen needles, glucagon.

Typical PA TAT

24–72h

Owners

Pharmacy, CDE, Case Manager

Triggers

New diabetes diagnosis
Insulin start
Severe hypoglycemia event

Workflow

1.CDE / pharmacy education + teach-back
2.Supplies ordered (CGM via DME, strips via pharmacy)
3.App / receiver setup demonstrated

Partner integrations

Dexcom / Abbott LibreCGM systems
Edgepark / Solara MedicalCGM DME supplier
CoverMyMedsPA submission for CGM + strips

Common denial reasons

Insulin therapy not documented (CGM)

Hypoglycemia not documented

Quantity > 100 strips/mo without insulin

Routes that use this

homehome with hh

Watch-outCGM PA criteria are tight; insulin use must be documented. Glucagon should be in every DM1 patient's box.

♡

Cardiac monitoring (event monitor, ILR, CardioMEMS)

Outpatient cardiac telemetry / implanted monitors for arrhythmia or CHF.

Typical PA TAT

48–96h

Owners

Cardiology, Case Manager

Triggers

Syncope workup
AFib / arrhythmia surveillance
Advanced CHF (NYHA III–IV)

Workflow

1.Cardiology orders device
2.Vendor matched + shipped (event monitor) or planted (ILR / CardioMEMS)
3.Remote monitoring set up + cardiology clinic notified

Partner integrations

iRhythm ZioPatch event monitor
Medtronic CareLinkILR / CardioMEMS remote monitoring
Abbott Merlin.netICD / pacer remote monitoring

Common denial reasons

Symptoms not documented

Shorter device not tried

Routes that use this

homehome with hh

Watch-outCardioMEMS requires implant procedure — schedule before DC if appropriate.

Social determinants · 3 categories

⌂

Home safety modifications

Grab bars, ramps, raised toilet seats, stairlift assessment.

Typical PA TAT

1–3 weeks (charity intake)

Owners

OT, Social Worker

Triggers

Fall history
New mobility limitation
Stairs at home + no alternative bedroom

Workflow

1.OT home safety eval
2.Recommendations prioritized + funding source identified
3.Charity / waiver / private install

Partner integrations

Rebuilding TogetherCharity home mods for low-income
Area Agency on AgingSenior-specific funding

Common denial reasons

Funding not available

Owner consent missing (renters)

Routes that use this

homehome with hh

Watch-outSlow to obtain; CM can discharge with portable safety items (commode + grab bars) while permanent install is scheduled.

✿

Food + nutrition

Meals on Wheels, Mom's Meals, CHF-friendly meal programs, SNAP enrollment.

Typical PA TAT

2–5 days

Owners

Dietitian, Social Worker

Triggers

Food insecurity screen positive
Disease-specific diet

Workflow

1.SW + dietitian assess + match to program
2.SNAP enrollment if eligible
3.Meals delivered post-DC; adherence tracked in portal

Partner integrations

Mom's MealsMA-contracted 14d post-DC meals
Project Open HandCharity meals
211 Bay AreaSNAP enrollment navigator

Common denial reasons

Plan benefit exhausted

Geography limit

Routes that use this

homehome with hhalfhospice home

Watch-outVolume limits + delivery window; confirm enrollment before discharge.

⌂

Housing + SDOH supports

Shelter, respite, rental assistance, utility help, legal aid, immigration.

Typical PA TAT

Days to weeks (community capacity)

Owners

Social Worker, Community Health Worker

Triggers

Homeless or housing-insecure
Utility shut-off threat
Legal / immigration crisis

Workflow

1.SW screens (PRAPARE / AHC tool)
2.Match to community partner
3.Warm handoff with appointment

Partner integrations

Mercy HousingSubsidized rental
Bay Area Legal AidPro bono guardianship + immigration
211 Bay AreaUniversal SDOH navigator
PG&E LIHEAPUtility shut-off prevention

Common denial reasons

Waitlist

Documentation gaps

Routes that use this

homehome with hhshelter respite

Watch-outCommunity capacity + waitlists are real; build long-term relationships with partners.

Skilled services · 4 categories

✚

Wound care supplies + skilled visits

Complex dressings + weekly RN visits for skilled wound care.

Typical PA TAT

24–48h

Owners

Wound RN, Case Manager

Triggers

Surgical wound complications
Pressure injury
Diabetic ulcer

Workflow

1.Wound RN consult inpatient
2.Supply order + HH skilled visit scheduled
3.Patient + caregiver education on dressing changes

Partner integrations

VNA Bay Area / Sutter Home CareSkilled wound RN
Medline / EdgeparkWound supplies

Common denial reasons

Caregiver capable of dressing changes (skilled denied)

Frequency not supported

Routes that use this

home with hhsnf

Watch-outSupply chain bottlenecks on specialty foam dressings.

≈

Outpatient dialysis (HD, PD, home)

In-center or home dialysis chair / training at discharge.

Typical PA TAT

24–72h (chair-limited)

Owners

Nephrology, Case Manager

Triggers

New ESRD
Transient AKI on CKD
Travel dialysis

Workflow

1.Nephrology consult + access plan
2.Chair secured (Fresenius, DaVita, US Renal)
3.Insurance confirmed; transport scheduled

Partner integrations

Fresenius Kidney CareIn-center HD network
DaVitaIn-center HD + home
US Renal CareIndependent network

Common denial reasons

Chair scarcity (regional)

Out-of-network shift

Routes that use this

homehome with hhsnf

Watch-outTue/Thu PM chairs scarcest; book early. Transport must align with chair times.

✤

Mental health follow-up

Outpatient psychiatry, therapy, peer support, crisis line.

Typical PA TAT

3–7 days (slot-limited)

Owners

Social Worker, Psychiatry, Case Manager

Triggers

Acute depression / suicidality
Substance use diagnosis
Bridge from inpatient psych

Workflow

1.SW assessment + warm handoff
2.Outpatient slot secured
3.Safety plan + crisis resources at discharge

Partner integrations

Westside Community ServicesOutpatient BH
BetterHelp / TalkspaceTelehealth therapy
988 Crisis LineCrisis safety net

Common denial reasons

Out-of-network

Higher level of care needed first

Routes that use this

homehome with hhshelter respite

Watch-outSlot availability is regional + insurance-network limited. Crisis number must be in DC packet.

→

Transport home / to next setting

See Logistics library for full options. Surfaced as a need for completeness.

Typical PA TAT

24h (≥48h advance ideal)

Owners

Case Manager

Triggers

No family vehicle
Wheelchair-bound
Long-distance transfer

Workflow

1.See Logistics library
2.Booked by CM with vendor
3.Confirmed with patient + family in portal

Partner integrations

ModivCareMedicaid + MA NEMT broker
Uber HealthPre-credentialed rideshare
AMR / FalckAmbulance (BLS / ALS)

Common denial reasons

Lower level of transport possible

Out-of-area

Routes that use this

homehome with hhsnfarultac

Watch-outLead time + plan-specific vendor matter; book ≥24h ahead for SNF transfer.

Education & teaching · 1 categories

✎

Disease + medication education

Plain-language teaching + caregiver coaching for chronic condition + new meds.

Typical PA TAT

Same day

Owners

RN, Pharmacy, AI Agent

Triggers

New chronic dx
High-risk medication added
LEP or low health literacy

Workflow

1.RN identifies education needs
2.Portal-translator agent re-renders at 6th-grade level
3.Patient + caregiver complete videos + ack
4.Teach-back at bedside before discharge

Partner integrations

HealthwiseExit / KramesStock education library
Anthropic Claude (via runAgent)Plain-language re-render

Routes that use this

homehome with hhsnfaru

Watch-outLEP / low literacy — interpreter required + 6th-grade reading level adjustment.

⚙How this screen works

Needs library is the bridge between clinical reality and payer rules

Inputs

What this screen reads

Per-need clinical triggers from cockpit barriers + chart
Patient's verified payer plan (X12 271)
Partner-rule library per need category

Engine

What it computes

Maps need → payer coverage status (covered / PA / patient-pay / not covered)
Surfaces partner integration path (CoverMyMeds, Parachute, Coram, etc.)
Flags common denial reasons before submission
Cross-refs which route options need this

Outputs

What it writes / routes

Cockpit coverage matrix pre-populated per patient
PA drafting pipeline (AI drafts → human reviews → CoverMyMeds submit)
Patient-pay risk flagged to CM + caregiver

Refresh trigger

When it updates

Plan change (new payer effective date)
Formulary update via Surescripts
PA decision webhook

Partners involved:CoverMyMeds (Rx PA)Availity (medical PA)Surescripts (formulary)Coram / Option Care / Accredo (specialty + infusion)Parachute Health (DME aggregation)

Demo data · no PHI · mocked Epic + payer endpoints