Post-acute home care for bundled payment programs — CJR-X and TEAM aligned.
The model: a W-2 care coordinator in the patient home within 48 hours of discharge. Daily wound, medication, and vitals monitoring across the full 90-day episode. Omaha System outcomes coded to your EHR.
Where this stands. BundledCare is a designed episode program, not a staffed service operating today. The economics, the Omaha System outcome set and the FHIR return format are built and are what we bring to a conversation. The caregiver workforce is contracted per engagement — we are not currently staffing home visits, and we will say so before any pilot is scoped rather than after.
For patients, families and discharge planners: Before you leave the hospital, build a printable question list →
A populated example of what one BundledCare episode is designed to include, end to end, for a CJR-X joint replacement.
Toggle the post-acute services your 90-day episode needs. Your selection carries into the contact form, so nobody retypes it. This is a program design, not open yet: the scope starts a conversation.
Post-acute services
7 selected
A program design, not a staffed service today. Nothing here is for sale.
Bundled payment programs reward health systems for outcomes across the full care episode. Home care is the last mile — and the highest-risk window for readmissions.
The episode is built around a W-2 care coordinator in the patient home within 48 hours of discharge — daily check-ins, vitals tracking, and physician escalation pathways. W-2, not 1099, is the design choice that makes the escalation pathway accountable.
Structured protocols for wound change, pain escalation, and fall risk. Every escalation documented and transmitted to the attending via FHIR-compatible feed.
All care coded in the Omaha System — the same taxonomy your quality reporting requires. Data flows directly into your EHR, no manual abstraction.
CMS proposed CJR-X — mandatory nationwide joint replacement episodes — in the FY2027 IPPS rule (April 2026). The TEAM model expands bundled payments to five surgical categories starting January 2026. BundledCare is designed to operate inside both structures.
Comprehensive Joint Replacement — Expanded
Transforming Episode Accountability Model
The Strategic Position
“Home care is the post-acute lever that most bundled payment programs have not yet operationalized.”
The highest-cost events in a 90-day episode are unplanned readmissions. Structured in-home follow-up reduces the most common causes.
Daily wound inspection and documented care protocol with escalation pathway to attending
In-home medication reconciliation and adherence monitoring at every visit
Home environment assessment and fall prevention protocol within 48 hours of discharge
Coordination of outpatient follow-up appointments and transportation barrier identification
avg. cost of an unplanned readmission
CMS claims data
Medicare joint replacement patients readmitted within 90 days, in higher-risk cohorts
Medicare claims / bundled payment studies
designed time to the first home visit
Design target, not a staffed service today
What a readmission costs the episode, and what a home episode is designed to do about it.
Built per-visit native: every visit is logged, attributed to a named caregiver, and auditable. As Medicare payment moves toward verified, visit-level care — the direction GAO recommended for hospice in June 2026 — our documentation is already shaped that way.
Fragmented post-acute. No eyes in the home.
A designed 90-day episode. Not staffed or open today.
The Business Case
Under a bundle, every readmission that does not happen is money the accountable hospital keeps against its target price. Whether a home episode is worth it depends on your volume and your readmission rate. The calculator below runs that on your own numbers.
BundledCare
CJR-X · MS-DRG 469 / 470
avg. cost of an unplanned readmission
CMS claims data
episode window
discharge to day 90
readmission
a TEAM quality measure
The cohort math
What the designed episode includes
Sources as cited on bundledcare.com: CMS claims data · NEJM bundled payment studies.
Three steps from discharge to active home care coverage.
Your care coordinator identifies eligible patients at discharge. We receive a referral — name, diagnosis, discharge date, and attending. No integration required to start.
A W-2 care coordinator contacts the patient within 24 hours and completes the in-home assessment within 48 hours. Episode documentation begins immediately. Coordinators are recruited and contracted against a scoped cohort, so this step begins at pilot design, not at signature.
Weekly structured reports delivered to your care team. Full FHIR-compatible data export available. Outcomes tied to CJR-X and TEAM quality metrics.
A 71-year-old woman. Bilateral knee replacement. Discharged day 3. Below are two versions of her next 90 days.
Discharged with a four-page packet and a follow-up appointment in three weeks. Her daughter drives an hour each way on Sundays. The visiting nurse comes twice, then the insurance authorization lapses.
Day 12: wound drainage. She waits two days before calling. The attending recommends she come in. No ride arranged. She calls 911.
Day 14: readmitted. Four days inpatient. Wound debridement. The episode cost — which started at $28,000 — closes at $47,200.
The readmission is attributed to the index DRG. The hospital absorbs the penalty under the bundled model. The surgeon is flagged for quality review.
A care coordinator calls within 24 hours of discharge. Home visit completed day 2. Wound documented with photos. Medication reconciliation done in-home. Fall hazards removed from the bedroom and bath.
Day 12: wound inspection shows early drainage. Care coordinator documents and escalates to attending same day. She is seen at clinic the next morning. Oral antibiotics, no admission needed.
Day 30 follow-up: home exercise program on track. No readmission. Episode closes on schedule. Weekly reports delivered to the care team.
Illustrative episode based on CMS claims averages for TKA (DRG 470) and published readmission cost data. Individual episodes vary.
Enter your joint replacement program data to see what readmissions cost your episodes today, and what each point of readmission rate is worth.
At 500 episodes/year with a 12.0% readmission rate, you spend $1.1M on readmissions annually. Each percentage point off that rate keeps about $90K a year against your episode budget.
60
Annual readmissions
$1.1M
Annual readmission cost
$90K
Per 1-point drop in rate, per year
Your inputs only. This is arithmetic on your numbers, not a projection of what BundledCare would achieve: it is a program design with no outcome data yet.
Get a customized analysis for your program, including CJR-X readiness and CMS bundled payment strategy.
We work with health system administrators and care coordinators to design home care coverage that fits your episode structure and quality reporting requirements.
Reply within 48 hours
We will reply to confirm your inquiry and schedule a discovery call.
Episode cost analysis
We will prepare a customized episode cost model based on your patient volume, procedure mix, and current readmission rate.
Integration assessment
We will review your EHR and quality reporting requirements to confirm FHIR compatibility and data return format.
Pilot design
For qualified health systems, we can design a 90-day pilot with a defined patient cohort and measurable readmission endpoints.
Questions before scheduling? Visit harnesshealth.ai/health-systems or use the form above — we reply within 48 hours.