Post-acute home care for bundled payment programs

Bundle home care into
your care episode.

One subscription. Better outcomes.

Add post-acute home care to your bundled payment program. $59 per patient per month. 90-day episode. Reduce readmissions and episode cost.

Example Bundle

Total Knee Replacement — 90-Day Episode

A populated example of what one BundledCare episode looks like, end to end. Drop-in pricing for a CJR-X joint replacement.

Bundle Price
$177
per patient, full 90-day episode
Billed as $59/month × 3 months. One avoidable readmission ($15K+ avg) funds 84+ episodes.
CMS Episode Reference
CJR-X · MS-DRG 469 / 470
What's Included
  • 48-hour post-discharge home deployment
    W-2 coordinator on site within 2 days
  • Daily check-ins for 14 days, then 3×/week
    Vitals, wound, pain, mobility, fall risk
  • Wound inspection and documented protocol
    Photo capture, escalation to attending via FHIR
  • Physical therapy adherence coaching
    Home exercise program tracked against PT plan
  • Medication reconciliation and refill alerts
    DVT prophylaxis, pain step-down, anticoagulation
  • 24/7 escalation pathway to surgeon on call
    Structured triage — wound, pain, fall, fever
  • Omaha System outcomes coded to your EHR
    No manual abstraction, audit-ready quality data
$15,000+
avg readmission cost
90 days
episode window
84×
break-even ratio
$59
per patient per month
90-day
episode coverage
2,500+
hospitals under CJR-X
FHIR
compatible data feed
The Model

Post-Acute Home Care as Episode Infrastructure

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.

90-Day Episode Coverage

We deploy a W-2 care coordinator to the patient home within 48 hours of discharge. Daily check-ins, vitals tracking, and physician escalation pathways built in.

48-hour deployment

Clinical Escalation Pathways

Structured protocols for wound change, pain escalation, and fall risk. Every escalation documented and transmitted to the attending via FHIR-compatible feed.

Zero-gap handoff

Omaha System Outcomes

All care coded in the Omaha System — the same taxonomy your quality reporting requires. Data flows directly into your EHR, no manual abstraction.

EHR-ready data
We operate the home care. You get the outcomes data.
Regulatory Alignment

Built for CJR-X and the TEAM Model

CMS proposed mandatory nationwide joint replacement episodes in 2025. The TEAM model expands bundled payments to five surgical categories. BundledCare is designed to operate inside both structures.

CJR-X

Comprehensive Joint Replacement — Expanded

  • Nationwide mandatory coverage for 2,500+ hospitals
  • 90-day episodes for hip and knee replacement
  • Target price includes post-acute services
  • Readmission penalties erode shared savings
  • Home care reduces SNF utilization and cost

TEAM Model

Transforming Episode Accountability Model

  • Expands bundled payments to five surgical categories
  • CABG, LEJR, spinal fusion, hip fracture, major bowel
  • Performance-based reconciliation, upside and downside
  • Quality metrics include 30-day readmission rates
  • Post-acute coordination is a direct cost lever

The Strategic Position

“Home care is the post-acute lever that most bundled payment programs have not yet operationalized.”

The Clinical Case

Readmission Reduction

The highest-cost events in a 90-day episode are unplanned readmissions. Structured in-home follow-up reduces the most common causes.

Wound Complications

Daily wound inspection and documented care protocol with escalation pathway to attending

Medication Non-Adherence

In-home medication reconciliation and adherence monitoring at every visit

Fall Risk

Home environment assessment and fall prevention protocol within 48 hours of discharge

Missed Follow-Up

Coordination of outpatient follow-up appointments and transportation barrier identification

$15,000+

avg. cost of an unplanned readmission

CMS claims data

1 in 5

joint replacement patients readmitted within 90 days

NEJM bundled payment studies

$59/mo

per patient cost of home care coverage

BundledCare subscription

Episode Cost Analysis

The Episode Economics

What home care costs versus what a readmission costs. The math is straightforward.

Without Structured Home Care

Fragmented post-acute. No eyes in the home.

  • SNF utilization averages 18-22 days per episode
  • No systematic wound or medication monitoring
  • Readmission rate 18-22% within 90 days
  • Each readmission costs $15,000+ in episode budget
  • Quality score penalties on readmission metric
  • No usable home-care data in EHR

With BundledCare

$59/patient/month. 90-day episode. Fully documented.

  • W-2 care coordinator in home within 48 hours
  • Daily wound, medication, and vital sign documentation
  • Escalation pathway reduces avoidable readmissions
  • Episode home-care cost: $177 per patient (3 months)
  • Omaha System outcomes feed directly to your EHR
  • FHIR-compatible data for quality reporting

The Business Case

Preventing one readmission in a 100-patient cohort saves $15,000 in episode cost. BundledCare costs $17,700 to cover that same cohort for the full 90-day episode. One avoidable readmission prevented funds the program.

Integration

How We Integrate With Your Program

Three steps from discharge to active home care coverage.

1

Patient Referral

Your care coordinator identifies eligible patients at discharge. We receive a referral — name, diagnosis, discharge date, and attending. No integration required to start.

2

Deployment

A W-2 care coordinator contacts the patient within 24 hours. In-home assessment completed within 48 hours. Episode documentation begins immediately.

3

Data Return

Weekly structured reports delivered to your care team. Full FHIR-compatible data export available. Outcomes tied to CJR-X and TEAM quality metrics.

Episode Cost Calculator

Enter your joint replacement program data to see the financial impact of reducing readmissions with co-op.care.

Talk to our team

Get a customized analysis for your program, including CJR-X readiness and CMS bundled payment strategy.

For Health Systems

Talk to us about your bundled payment program.

We work with health system administrators and care coordinators to design home care coverage that fits your episode structure and quality reporting requirements.

Request a Conversation

What to expect

Response within one business day

A member of our clinical operations team will respond 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.

Prefer to reach us directly? Send inquiries to partnerships@bundledcare.com or visit harnesshealth.ai/health-systems