2.3.1 Patient Population: Lower-acuity patients eligible for early discharge, including those with chronic conditions and post-acute care needs. 2.3.2 Service Goals: • Facilitate safe, timely hospital discharge. • Provide hospital-level care and monitoring in the home environment. • Engage patients in follow-up and chronic disease management. • Reduce readmissions and emergency department visits. 2.3.3 Key Components: • Remote monitoring of vital signs and relevant clinical parameters. • Daily or as-needed virtual and/or in-person clinical assessments. • Patient and caregiver education and support. • Integration with existing EHR and care coordination workflows. • Bedside, wearable, or mobile monitoring devices • Real-time or scheduled transmission of patient vitals • Automatic charting of validated data into the Epic EMR • Configurable triggers for clinical alerts and code activations • Tools to assist in discharge-readiness assessment and care transition coordination • Options for centralized/virtual nursing support and reduced bedside workload
