CarePathIQ — Episode Intelligence Platform

CarePathIQ · Episode Intelligence Platform · Prototype Concept

The right care path,
for every patient,
before they leave the building.

Discharge planners spend hours matching patients to post-acute care, chasing prior authorizations, and hoping the 90-day episode stays on track. CarePathIQ uses outcome data from thousands of similar patients to surface the best pathway at the moment of discharge — and monitors the episode through every care transition until the patient is safely home.

34%

Lower 30-day readmission
when AI pathway is followed

4 min

To generate a prior auth
package vs. 2+ hours manual

$3.2M

Estimated avoided readmission
costs across 1,847 episodes

847

Similar patients analyzed
for Dorothy's pathway match

🧭

Care Pathway Rx

AI matches each patient to an outcome-optimized post-acute pathway based on diagnosis, functional status, comorbidities, payer, and social risk — surfacing the best-fit SNF or HHA from real episode data.

Open →

📈

90-Day Episode Dashboard

Tracks each patient from hospital discharge through SNF, home health, and community — with live alerts when something goes off-track before it becomes a readmission.

Open →

🏥

Network Intelligence

Episode-level outcome data across every SNF and HHA in the network — sorted by patient profile match, not just CMS stars — so discharge planners and ACO leaders can build networks on what actually works.

Open →

📋

Prior Authorization

AI generates the clinical justification package in 4 minutes, auto-matches payer-specific criteria, and schedules concurrent reviews — reducing denials by addressing the three most common failure points before submission.

Open →

The Problem Today

Discharge planners match patients to post-acute care based on relationships and habit — not outcome data

Prior auth packages are built manually from scratch for each patient, taking 2+ hours with high denial rates

Episode monitoring is fragmented — no single view of what's happening to a patient across care settings

Network decisions are made using CMS stars and contracts — not actual outcome data by patient profile

Readmissions are caught late, when intervention is no longer effective

Who CarePathIQ Serves

Hospital discharge planners — spend less time on paperwork, more time on patients. The AI does the matching and the auth package; they review and approve.

ACO and value-based care leaders — network design and contract negotiations backed by real episode performance data, not just stars.

SNF and HHA operators — understand exactly which patient profiles they perform best with, and use that data to win referrals.

Payers — receive complete, well-documented auth packages with outcome evidence, reducing back-and-forth and accelerating decisions.

⚠ Prototype concept — All patient names, clinical data, facility names, and outcome statistics in this prototype are entirely fictional and created for demonstration purposes only. This is not a real clinical tool and is not for clinical use.

Facility

St. Mary's Medical Center · Orthopedic Unit

Procedure

Total Left Knee Arthroplasty (TKA)

Surgeon

Dr. Patricia Mendez

Discharge Date

February 19, 2026

DRG 470 — identical on paper

A

Margaret S., 87F

TKA · Complex profile · High medical burden

COPD Type 2 Diabetes Early Cognitive Decline Assisted Living

Age87 years

Living situationAssisted Living · 24-hr staff

Primary caregiverDaughter, 2× visits/week

Pre-op functionModerate assist · 3 of 6 ADLs

FIM at discharge68 / 126

Active medications14 · Metformin, Spiriva, Aricept

Cognitive statusEarly MCI · CDR 0.5

Complexity Profile

Medical complexity

High

Social support

Mod

Cognitive risk

High

Therapy tolerance

Mod

Discharge env. safety

OK

Same
DRG

VS

Same
surgeon

B

Robert K., 80M

TKA · Typical profile · Low medical burden

Hypertension Hyperlipidemia Lives with spouse Fully independent

Age80 years

Living situationHome with spouse · Active caregiver

Primary caregiverSpouse · Full-time, highly capable

Pre-op functionFully independent · 6 of 6 ADLs

FIM at discharge104 / 126

Active medications5 · Lisinopril, Atorvastatin

Cognitive statusIntact · No concerns

Complexity Profile

Medical complexity

Low

Social support

High

Cognitive risk

Low

Therapy tolerance

High

Discharge env. safety

High

✦ AI Reasoning · Margaret — Why SNF First

CLINICAL ANALYSIS

COPD, Type 2 Diabetes, and early MCI are each independently associated with extended post-acute stays and elevated readmission risk. Together, they create a compounding profile that makes direct home discharge unsafe. Respiratory tolerance will limit therapy intensity — Margaret cannot sustain the standard 60+ min/day PT/OT cadence without risk of COPD exacerbation, so a slower progression paced to O2 sat is indicated. Diabetes complicates wound healing and increases infection risk, requiring daily nursing monitoring that her Assisted Living cannot provide at the level a SNF can. The early cognitive decline means care instructions must be simplified, routines kept consistent, and family communication prioritized — her daughter is a key information bridge but is not a daily caregiver. Recommended: SNF admission, target 14–21 days, with warm handoff to the AL memory support team at discharge.

✦ AI Reasoning · Robert — Why Home First

CLINICAL ANALYSIS

Robert presents a straightforward post-acute profile. Hypertension and hyperlipidemia are both medically managed and do not significantly complicate TKA recovery. Full pre-op ADL independence at 80 is a strong predictor of return-to-baseline function within 45 days. The presence of a capable, full-time spousal caregiver at home substantially reduces readmission risk — caregiver presence is one of the strongest protective factors in post-surgical orthopedic recovery, consistently outweighing age alone as a predictor of outcome. His FIM of 104 at discharge indicates near-normal functional baseline has already been restored before leaving the hospital. Recommended: Direct home health discharge, PT 3×/week for 6 weeks, standard orthopedic protocol. No SNF admission indicated. Expected return to prior activity level by Day 45.

Margaret · SNF First Pathway

14–21

Days in SNF

78%

Predicted episode
success rate

9.2%

30-day readmit
risk (avg 22%)

Robert · Home First Pathway

0

SNF days needed

91%

Predicted episode
success rate

5.1%

30-day readmit
risk (avg 22%)

Margaret's Pathway — Complex / SNF First

High complexity

🏥

Hospital → SNF admission

Skilled nursing required for wound management, respiratory monitoring, insulin protocol, and cognitive-adapted therapy. Direct home discharge not safe given complexity and limited AL daytime supervision.

Target SNF LOS: 14–21 days

🫁

SNF: Paced therapy with respiratory monitoring

PT/OT reduced to 30–40 min sessions (vs standard 60 min). O2 sat checked before and after each session. Diabetes wound protocol q-shift. Cognitive-consistent daily routine with same staff preferred.

🧠

Cognitive screening at Day 7 and Day 14

Post-surgical delirium risk elevated with pre-existing MCI. MMSE or MoCA at Day 7 establishes baseline. Family care conference recommended by Day 5 with daughter and AL memory team.

⚠ Delirium risk elevated

🏡

SNF discharge → Assisted Living with HHA bridge

Warm handoff to AL with written cognitive care plan. Home health for wound check and PT continuation 2×/week. HHA must have memory care competency.

HHA: Memory-care certified required

📊

CarePathIQ monitoring: 60-day episode

Weight, O2 sat, therapy engagement, cognitive behavior patterns, and family visit frequency tracked simultaneously. Simultaneous decline in two or more signals triggers 48-hour clinical review.

Robert's Pathway — Standard / Home First

Low complexity

🏡

Hospital → Home with spouse caregiver

FIM 104, fully independent pre-op, full-time spousal caregiver at home. No skilled nursing indicated. Standard orthopedic home health protocol initiated on Day 1 post-discharge.

Direct home discharge appropriate

🏋️

Home health: PT 3×/week, standard protocol

60 min sessions tolerated. Full weight-bearing per surgeon protocol. Stair training, gait normalization, progressive ROM. Spouse attends all sessions — strong learning partner for home exercise program.

💊

Medication management: minimal complexity

Anticoagulation per protocol (likely 2–4 weeks aspirin). HTN and lipid meds continue unchanged. No insulin, no respiratory meds, no cognitive support needs. Spouse manages medications reliably.

📈

Projected discharge from HH: Day 35–45

Expected return to prior activity level (golf, walking) by Day 45–60. Outpatient PT transition at HH discharge for continued strengthening. No SNF admission needed at any point in the episode.

Projected: Full ADL independence by Day 45

📊

CarePathIQ monitoring: 45-day episode

Simplified monitoring: ROM progression, pain trajectory, HEP compliance via spouse report. No cognitive or respiratory flags active. Episode closes at Day 45 if trajectory holds.

✦ What This Demonstrates

Two patients walk out of the same OR on the same day with the same billing code. A traditional discharge process routes them both to available beds based on relationships and habit. CarePathIQ reads their full clinical picture simultaneously — comorbidities, functional status, caregiver strength, cognitive risk, social determinants, and 847 similar-patient outcomes — and produces a fundamentally different recommendation for each. Margaret gets a SNF with memory-care certified HHA follow-through. Robert goes straight home and is fully independent 10 days sooner than the average similar patient. The difference isn't just clinical precision — it's avoided readmissions, appropriate resource use, and an episode that actually matches the patient in front of you.

Patient Profile

High Complexity

Primary Dx

Total Knee Replacement (L)

Comorbidities

COPD, DM Type 2, HTN

Functional Status

Mod. Assist · FIM 68/126

Cognitive

Intact · MMSE 27/30

Medications

14 active meds · High burden

Payer

Medicare A → B

Social Determinants

Lives alone Limited transport Fixed income Motivated Daughter nearby COPD — pulm. support needed

✦ AI Pattern Match

Among 847 similar patients (TKR + COPD, Medicare, moderate social risk) discharged from this facility in the past 3 years, those routed to a SNF with dedicated pulmonary therapy had a 34% lower 30-day readmission rate and 22% higher successful episode rate than those discharged directly to home health.

Predicted Episode Success

78%

LIKELY

High probability of successful episode

Based on AI modeling of 847 similar patients. Success defined as: no readmission, no ED visit, functional improvement ≥15%, and discharge to community within 90 days.

30-day readmission risk 14% (avg 22%)

Projected total LOS 36 days across settings

Est. episode cost $18,400 (−12% vs avg)

Key Risk Drivers

🫁

COPD exacerbation risk

Post-surgical respiratory complications are primary readmission driver for this profile

🏠

Home safety gap

Lives alone — home assessment and equipment needed before any discharge to home

Recommended Care Pathway

Within 25 miles · Sorted by outcome match

1

🏥 Skilled Nursing Facility — Riverside Rehab & Care

3.8 mi · 5★ CMS · Dedicated pulmonary therapy 5x/week · PT/OT 6 days · 94% similar-patient success rate · Medicare certified

Top match for COPD Strong PT outcomes Bed available today

18–21

est. days

✓ 94% match

2

🏡 Home Health Agency — Comfort Care Home Health

Primary service area covers patient's zip · 4.5★ · Wound care certified · Medication management · Telehealth respiratory monitoring available

Respiratory monitoring Medication mgmt

14–21

est. days

✓ 88% match

3

🟢 Community / Independent — Outpatient PT + PCP Follow-Up

Outpatient PT 3x/week · PCP visit within 7 days of home health discharge · Pulmonologist follow-up within 30 days · Daughter to support medication adherence

Ongoing

community

SNF Comparator — 25 Mile Radius

Filtered for: TKR + COPD patient profile · Medicare

Facility	CMS Stars	Pulm. Therapy	Similar-Pt Success	30-Day Readmit	Dist.	Availability
Riverside Rehab & Care ✦ Top AI Match	★★★★★	5x/week	94%	9.2%	3.8 mi	Available
Summit Gardens SNF	★★★★☆	3x/week	79%	16.1%	7.1 mi	Available
Valley View Care Center	★★★☆☆	1x/week	61%	24.7%	5.2 mi	2-day wait
Pinebrook Skilled Care	★★★★☆	2x/week	72%	18.4%	12.4 mi	Available

Episode Day

43

of 90 · On track

Success Probability

74%

↑ from 68% at Day 21

Active Alerts

2

1 high · 1 medium priority

Care Journey Timeline

Setting of care

HOSP

SNF

HHA

HOME / COMMUNITY

Day 1 ▲ TODAY Day 43 Day 90

Key events

Day 1: Admission

TKR surgery completed

Day 4: SNF Admit

Riverside Rehab

Day 18: COPD Flag

O2 sat monitored — resolved

Day 25: HHA Start

Comfort Care HHA

Day 43: ⚠ Alert

Missed HHA visit flagged

Active Alerts

Action needed

⚠️

Missed Home Health Visit — Day 41

Comfort Care HHA reports patient did not answer door for scheduled wound check. No contact made. This patient's profile carries elevated readmission risk if wound complications go undetected. Recommend immediate outreach.

💊

Medication Adherence Concern

Patient reported to HHA nurse that she is taking COPD inhaler "when she remembers." Missed doses increase exacerbation risk. Daughter contact may help establish routine.

✅

Functional Progress on Track

PT reports ambulating 150ft independently with walker. FIM motor score improved from 48 to 67 since SNF admit. On track for outpatient PT transition by Day 55.

Outcome Measures — Current

Readmission (30-day)None ✓

ED VisitsNone ✓

FallsNone ✓

Functional improvement+19 FIM pts ✓

Wound healing status⚠ Unconfirmed Day 43

Medication adherence⚠ COPD inhaler concern

Patient satisfaction4.6/5.0 ✓

Provider Communication

DAY 43 · TODAY

Comfort Care HHA

Missed visit reported. Attempted patient contact x2.

DAY 39

Dr. Patel, PCP

Follow-up visit completed. COPD stable. Continue current plan.

DAY 25

Riverside Rehab — Discharge

SNF d/c summary sent. Wound healing well. HHA referral confirmed.

DAY 18

Riverside Rehab — COPD Alert

O2 sat 91% during PT. Pulm consult ordered. Resolved Day 20.

Payer Summary

Medicare A/B

Episode cost to date$11,240

Projected total$18,200

Budget vs. benchmark−8.4% ✓

Quality score (current)84/100

Episodes Tracked

1,847

Last 18 months

Network Avg Success Rate

71%

↑ 6pts vs. prior period

Avoided Readmissions

214

Est. $3.2M savings

SNF Performance — Success Rate vs. Readmission Rate

● Bubble size = episode volume Tier 1 Tier 2 Tier 3

EPISODE SUCCESS RATE →

30-DAY READMISSION RATE →

Riverside
Rehab

Summit
Gdns

Pine-
brook

Valley
View

Lakeside
Care Ctr

Meadows

✦ PREFERRED NETWORK

⚠ REVIEW / REMOVE

Preferred Network Rankings — SNF

Used for contract negotiation · ACO network design · Discharge planning guidance

Facility	Tier	Episodes	Success Rate	30-Day Readmit	Avg Episode Cost	Best For	Trend
Riverside Rehab & Care	Tier 1	187	94%	9.2%	$17,800	Pulm · Ortho · Complex	↑ +4pts
Meadows SNF	Tier 1	76	81%	14.8%	$16,200	Cardiac · Neuro	↑ +2pts
Summit Gardens SNF	Tier 2	142	79%	16.1%	$18,100	Ortho · Low complexity	→ Stable
Pinebrook Skilled Care	Tier 2	98	72%	18.4%	$19,400	Overflow only	↓ −1pt
Valley View Care Center	Tier 3	156	61%	24.7%	$22,600	Under review	↓ −5pts
Lakeside Care Center	Not Recommended	203	52%	29.3%	$25,100	Remove from network	↓ −8pts

4 min

Package generated

~2 hrs

Avg manual time saved

94%

Approval probability

6%

Denial risk (avg 31%)

Denial risk vs. manual submission average

Well below average

AI-matched clinical evidence reduces missing documentation — the #1 cause of denials

✓Patient Profile

✓Clinical Criteria

✓Pathway Matched

✓Evidence Generated

5Ready to Submit

6Payer Decision

Clinical Justification — AI Draft

✦ AI GENERATED

✦ AI-Drafted Clinical Narrative — Review before submitting

Patient Dorothy R., 72-year-old female, presents following left total knee arthroplasty performed 02/15/2026 at St. Mary's Medical Center. Patient requires skilled nursing facility level of care based on the following clinical criteria:

Primary Diagnosis: Left total knee replacement (Z96.652) with comorbid COPD (J44.1), Type 2 Diabetes Mellitus (E11.9), and Hypertension (I10). The presence of COPD significantly elevates post-surgical respiratory monitoring requirements and necessitates daily pulmonary therapy unavailable in a home setting at this functional status.

Functional Status: Patient presents with FIM score of 68/126, requiring moderate assistance for all mobility and self-care activities. Current functional level is below the threshold for safe discharge to home even with home health support. Physical therapy 6 days per week and occupational therapy 5 days per week are medically necessary to achieve safe discharge functional status.

Skilled Care Requirements: Patient requires daily skilled nursing assessment for COPD monitoring (O2 sat trending 94% on room air), wound assessment and care (post-surgical incision site), medication management across 14 active medications including insulin sliding scale, and IV antibiotic course (Day 2 of 7). These services require licensed nursing and cannot be safely provided in a home setting at this time.

Anticipated Length of Stay: 18–21 days at SNF level, based on AI outcome modeling of 847 similar patients (TKR + COPD, Medicare Advantage, moderate social risk) at comparable functional status at time of discharge. Projected HHA transition on Day 22–25 pending functional reassessment.

⚠ Review AI draft before submitting. Clinician must verify accuracy and add any additional clinical context not captured in the record. This narrative was generated from structured patient data — not from clinical notes.

Supporting Clinical Evidence

Auto-pulled from patient record + outcome database

Evidence Type	Data Point	Source	Status
Functional Assessment	FIM Score 68/126 — Moderate Assist	Therapist eval 02/18	✓ Attached
Physician Orders	SNF admit order — Dr. Patel 02/18	EHR — St. Mary's	✓ Attached
Diagnosis Codes	Z96.652, J44.1, E11.9, I10 (4 total)	Discharge summary	✓ Verified
Respiratory Complexity	O2 sat 94% room air · COPD comorbidity	Vitals record	✓ Attached
Skilled Nursing Need	IV antibiotics Day 2/7 · Insulin sliding scale	MAR — current	✓ Attached
Outcome Evidence	94% success rate — similar patients at Riverside Rehab	CarePathIQ database	✦ AI-generated
Wound Assessment	Post-surgical wound — active management needed	Nursing note 02/18	✓ Attached
Social Risk Documentation	Lives alone · Limited transport · Fixed income	Social work screen	⚠ Pending SW sign-off

Payer-Specific Requirements — Humana Gold Plus HMO

Auto-matched to payer criteria

✅

3-day qualifying hospital stay — Required for Medicare SNF benefit

Met · 4 days

✅

Skilled care necessity — Daily skilled nursing or therapy required

Met · PT + SN daily

✅

Physician certification — Admitting physician order required

Met · Dr. Patel 02/18

✅

In-network SNF — Riverside Rehab & Care is Humana Gold preferred network Tier 1

Met · Tier 1

⚠️

Social work discharge planning note — Required by Humana for patients with documented social risk flags

Pending

✅

Functional assessment — FIM or Barthel score required within 24hrs of discharge

Met · FIM 68

⚠ 1 item pending: Social work sign-off needed before submission. Estimated 20 minutes to resolve. Authorization cannot be submitted without this.

Authorization Details

Patient

Dorothy R. · DOB 06/12/1953

Payer / Plan

Humana Gold Plus HMO · ID H8423901

Request type

SNF Admission — Post-Acute

Requested facility

Riverside Rehab & Care · NPI 1234567890

Requested dates

02/19/2026 – 03/11/2026 (21 days)

Primary Dx

Z96.652 — L Total Knee Replacement

Auth method

✦ AI-assisted package — clinician reviewed

Submission method

Humana HealthEdge Portal — direct API

Expected decision

2–4 hours (Humana SLA: same-day urgent)

📅 Concurrent Review Schedule

Auto-scheduled

Humana requires concurrent review at Days 5, 10, and 18. CarePathIQ will auto-generate updated clinical summaries 24 hours before each review date.

Day 5 Review

02/24 · Functional progress + skilled need

Auto-scheduled

Day 10 Review

03/01 · Discharge planning update

Auto-scheduled

Day 18 Review

03/09 · Extension request if needed

Auto-scheduled

✓ If functional progress benchmarks are met at Day 10, discharge transition to HHA will be automatically prepared and submitted to payer.

🔀 Multi-Payer Queue

Today · St. Mary's

Dorothy R. · Humana Gold

SNF 21 days · Package ready

⏳ Pending SW note

Harold T. · Medicare A

SNF 14 days · Auto-approved

✓ Approved

Carmen L. · UHC MA

HHA 30 days · Under review

⏳ Day 2 of 4

James W. · Aetna MA

SNF — missing PT eval

⚠ Action needed

Rita M. · Medicaid

LTC transition · Ready

→ Submit today

✦ Why This Package Has a 94% Approval Probability

The three leading causes of SNF prior auth denials for Medicare Advantage are: missing functional assessment (present — FIM 68), insufficient skilled care documentation (present — IV antibiotics + daily PT), and out-of-network facility (Riverside Rehab is Tier 1 preferred). All three are addressed. The only open item is the social work note, which is in process.