Post-acute home care for bundled payment programs — CJR-X and TEAM aligned.
BundledCare deploys a W-2 care coordinator to the patient home within 48 hours of discharge. Daily wound, medication, and vitals monitoring across the full 90-day episode. Omaha System outcomes coded directly to your EHR. $59 per patient per month — one readmission prevented funds 84 episodes.
A populated example of what one BundledCare episode looks like, end to end. Drop-in pricing for a CJR-X joint replacement.
Toggle the post-acute services a 90-day episode needs. Watch the à-la-carte total climb while the bundle holds at $177. That gap is the whole argument for bundled payment.
Post-acute services
7 selected
À-la-carte figures are illustrative list-style costs over a 90-day episode, shown to demonstrate the bundling effect — not a quote.
Illustrative only. Your episode price depends on volume, procedure mix, and scope.
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.
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.
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
per patient cost of home care coverage
BundledCare subscription
What home care costs versus what a readmission costs. The math is straightforward.
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.
$59/patient/month. 90-day episode. Fully documented.
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.
BundledCare
CJR-X · MS-DRG 469 / 470
avg. cost of an unplanned readmission
CMS claims data
per patient, full 90-day episode
billed as $59/month × 3 months
break-even ratio
one readmission prevented funds 84+ episodes
The cohort math
What $177 buys per patient
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. In-home assessment completed within 48 hours. Episode documentation begins immediately.
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: physical therapy adherence 91%. No readmission. Episode closes on schedule. Weekly reports delivered to the care team.
The episode cost lands at $29,400 — $177 of which is the BundledCare coverage subscription. The readmission that would have cost $19,000 did not happen.
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 the financial impact of reducing readmissions with BundledCare.
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.
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.
Questions before scheduling? Visit harnesshealth.ai/health-systems or use the form above — we respond within one business day.