Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Route library

Disposition options · where patients can go from inpatient
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Discharge mapRoutesLogisticsNeeds × coverageResource hub
Every discharge ends in one of these routes. OpenBed AI surfaces which are eligible for a given patient (clinical fit + payer + family choice), pre-validates coverage, and pre-warms the top 1–3. The chosen route locks the logistics path and the documentation packet.
Home (independent)
Home / community

Patient returns home without paid post-acute services.

Typical duration
Indefinite
Time to place
Same day
Owns referral
Hospitalist + RN (no external referral required)
Documents
Discharge summary · Med rec sheet · Follow-up appt
When to consider
  • ●Baseline functional status restored
  • ●Caregiver available or patient self-sufficient
  • ●Outpatient follow-up booked within 7 days
Eligibility
  • ADLs independent (or supported by caregiver)
  • Safe home environment
  • Med regimen manageable without skilled visits
Coverage at a glance
Medicare FFS
No post-acute cost; outpatient visits per plan
Medicare Advantage
Outpatient + benefit-specific (meals/transport) per plan
Medicaid
Outpatient + waiver programs by state
Commercial
Outpatient per plan
Risk if missedReadmit if outpatient appointment isn't scheduled in 7d.
Home + Home Health
Home / community

Home with skilled home health visits (RN, PT/OT, SLP, MSW, HHA).

Typical duration
30–60 days
Time to place
24–48h (start-of-care visit within 48h of DC)
Owns referral
Case Manager
Documents
HH referral · F2F encounter note (CMS-485 elements) · Plan of care
When to consider
  • ●Skilled need (wound, IV, teaching, gait training)
  • ●Patient homebound by Medicare definition
  • ●Caregiver support gaps fillable by intermittent visits
Eligibility
  • Medicare homebound definition met
  • Skilled need documented in F2F encounter note
  • Plan of care signed by physician within 30d
Coverage at a glance
Medicare FFS
Covered if homebound + skilled need (Part A)
Medicare Advantage
Covered with prior auth; benefit varies by plan
Medicaid
Covered in most states; auth required
Commercial
Covered per plan; auth + visit limits typical
Risk if missedSoC visit lapse → CMS audit risk + readmit climb.
Home + IV infusion
Home / community

Home with home-infusion vendor for IV antibiotics, chemo, hydration, or biologics.

Typical duration
2–6 weeks
Time to place
24–72h
Owns referral
Case Manager + Pharmacy
Documents
Infusion order · PICC documentation · Auth packet
When to consider
  • ●IV antibiotic course beyond hospital stay
  • ●Chemo or biologic infusions per oncology plan
  • ●Hydration / TPN for nutrition support
Eligibility
  • Stable hemodynamics + tolerating prior dose
  • PICC or port in place
  • Caregiver or pump-capable patient
Coverage at a glance
Medicare FFS
Part B for drugs + DME pump; nursing visit limited
Medicare Advantage
Coverage varies; auth common
Medicaid
State-dependent; often requires PA
Commercial
Specialty pharmacy carve-out common (e.g. Accredo, CVS Specialty)
Risk if missedDischarge slips waiting for first home-infusion visit.
Skilled Nursing Facility (SNF)
Post-acute facility

Short-term sub-acute rehab + skilled nursing in a facility setting.

Typical duration
7–30 days
Time to place
24–72h (bed + auth)
Owns referral
Case Manager
Documents
SNF referral packet · Auth approval · PT/OT eval + transfer note
When to consider
  • ●Cannot tolerate 3h/day of rehab (use SNF over ARU)
  • ●Skilled need but unsafe at home alone
  • ●Reconditioning after CHF, sepsis, ortho, stroke
Eligibility
  • Medicare: 3-night qualifying inpatient stay (waived for some MA plans)
  • MA: per plan rules — many waive 3-day
  • Skilled need daily (PT/OT, nursing, IV)
Coverage at a glance
Medicare FFS
Days 1–20 fully covered; 21–100 with daily copay
Medicare Advantage
Per plan; PA required; often shorter benefit window
Medicaid
Long-term custodial coverage; short-term skilled per state
Commercial
Per plan; PA + tiered network
Risk if missedBed lost over weekend; auth window misses; patient occupies acute bed.
Acute Rehab Unit (ARU / IRF)
Inpatient rehab facility

Intensive rehab — minimum 3h/day across PT/OT/SLP for ≥5 days/week.

Typical duration
10–21 days
Time to place
48–96h (auth-limited)
Owns referral
Case Manager + Physiatrist consult
Documents
IRF-PAI initial assessment · Auth packet · Therapy tolerance documentation
When to consider
  • ●Stroke, TBI, hip fx, spinal cord, major multi-trauma
  • ●Patient tolerates and benefits from 3h/day therapy
  • ●Two-discipline rehab need (PT + OT or PT + SLP)
Eligibility
  • CMS 60% rule diagnosis (stroke, hip fx, etc.) or documented need
  • Patient must tolerate 3h/day or be expected to soon
  • Physician supervision daily
Coverage at a glance
Medicare FFS
Part A; PA via CMS criteria (60% rule)
Medicare Advantage
PA required; many plans direct to SNF first
Medicaid
Covered per state; auth required
Commercial
PA + medical necessity review
Risk if missedPatient deconditions; loses ARU candidacy.
Long-Term Acute Care (LTAC)
LTACH hospital

Medically complex patients with average LOS > 25 days (vent weaning, complex wounds).

Typical duration
25–60 days
Time to place
72h–7 days
Owns referral
Case Manager + Pulmonary/Critical Care
Documents
Auth packet · Vent settings + wean plan · Wound documentation
When to consider
  • ●Prolonged ventilator weaning
  • ●Complex multi-system management beyond SNF capability
  • ●Daily MD oversight + RT required
Eligibility
  • Medicare interrupted-stay rules
  • Complexity score per LTAC criteria
Coverage at a glance
Medicare FFS
Part A; LTCH PPS rate
Medicare Advantage
PA + medical necessity review
Medicaid
State-dependent
Commercial
PA + case rate negotiation
Risk if missedPatient occupies ICU bed needing complex care unavailable on floor.
Hospice at home
Home / hospice agency

Comfort-focused care at home with hospice agency for life-limiting illness.

Typical duration
6 months or less prognosis
Time to place
Same day with capacity
Owns referral
Social Worker + Palliative team
Documents
Hospice election · Two MD certifications · POLST
When to consider
  • ●Prognosis ≤ 6 months
  • ●Goals of care shift to comfort
  • ●Family willing + able to provide caregiving
Eligibility
  • Two MD certs (referring + hospice medical director)
  • Election of hospice benefit (Medicare/MA/Medicaid)
Coverage at a glance
Medicare FFS
Hospice benefit covers MD, RN, MSW, chaplain, meds, DME
Medicare Advantage
Carved back to Original Medicare for hospice
Medicaid
Hospice benefit per state
Commercial
Per plan; some carve-out
Risk if missedPatient dies in acute setting; family / staff trauma.
Hospice inpatient unit (GIP)
Hospice IPU

Inpatient hospice for symptom management when home is not appropriate.

Typical duration
1–14 days typical
Time to place
Same day with bed
Owns referral
Palliative team + Social Worker
Documents
Hospice election · GIP criteria documentation
When to consider
  • ●Uncontrolled symptoms requiring 24h skilled management
  • ●Imminent death + family unable to manage at home
Eligibility
  • Hospice eligible + GIP criteria met
Coverage at a glance
Medicare FFS
Hospice GIP rate
Medicare Advantage
Carved back
Medicaid
Per state
Commercial
Per plan
Risk if missedPatient suffers; family distress; acute bed occupied.
Memory care / dementia unit
Memory care facility

Secure assisted-living unit for dementia / cognitive impairment.

Typical duration
Long-term
Time to place
1–4 weeks (waitlists common)
Owns referral
Social Worker
Documents
Cognitive eval · Funding verification · Guardianship if applicable
When to consider
  • ●Moderate–severe dementia with wandering risk
  • ●Family unable to safely supervise 24h
  • ●No skilled need (else SNF first)
Eligibility
  • Cognitive assessment + safety screen
  • Funding source (private pay, LTC insurance, Medicaid waiver)
Coverage at a glance
Medicare FFS
Not covered (custodial)
Medicare Advantage
Generally not covered
Medicaid
HCBS waiver in some states; LTC nursing home if available
Commercial
LTC insurance only
Risk if missedPatient super-stranded; legal/funding pending; weeks of avoidable days.
Assisted living facility (ALF)
Assisted living facility

Supportive housing with ADL help; not skilled.

Typical duration
Long-term
Time to place
1–2 weeks
Owns referral
Social Worker
Documents
ALF intake forms · Funding verification
When to consider
  • ●ADL help needed but not skilled care
  • ●Self-pay or LTC insurance
Eligibility
  • ADL eval
  • Funding source
Coverage at a glance
Medicare FFS
Not covered
Medicare Advantage
Not covered (some supplemental benefits)
Medicaid
Some HCBS waivers cover ALF in select states
Commercial
LTC insurance only
Risk if missedPatient pulled toward unnecessary SNF for funding reasons.
Long-term nursing home (custodial)
Nursing facility

Permanent placement for patients unable to live independently or with caregiver.

Typical duration
Indefinite
Time to place
Weeks (Medicaid pending = main delay)
Owns referral
Social Worker
Documents
Medicaid LTC app · Bed-hold agreement · Guardianship if applicable
When to consider
  • ●No safe community option
  • ●Family unable to provide 24h care
Eligibility
  • Medicaid LTC pending or approved
  • Functional + cognitive assessment
Coverage at a glance
Medicare FFS
Not covered (custodial)
Medicare Advantage
Not covered
Medicaid
Covered if Medicaid LTC eligible (income/asset test)
Commercial
LTC insurance only
Risk if missedMonths of super-stranded acute bed days while Medicaid processes.
Medical respite / shelter
Medical respite / shelter

Recuperative care for patients experiencing homelessness — community-based.

Typical duration
2–4 weeks
Time to place
1–7 days (capacity-limited)
Owns referral
Social Worker + Housing navigator
Documents
Respite intake · Behavioral screen
When to consider
  • ●Homeless or housing-insecure
  • ●Recovery requires more than shelter but not skilled SNF
Eligibility
  • Medical respite program intake criteria
  • Behavioral stability per program
Coverage at a glance
Medicare FFS
Not covered (some PACE programs)
Medicare Advantage
Some plans offer supplemental SDOH benefit
Medicaid
Some Medicaid managed-care plans contract with respite
Commercial
Generally not covered; charity/grant-funded
Risk if missedPatient discharged to street; readmission within days; ethical/legal exposure.
⚙How this screen works
Routes library defines the universe of possible discharge destinations
Inputs
What this screen reads
  • Clinical eligibility (six-pillar status + dx)
  • Payer plan + benefit window
  • Family / patient preference
  • Resource Hub capacity for matching kinds
Engine
What it computes
  • Filters routes by clinical eligibility per disposition criteria
  • Filters by payer (e.g. SNF needs 3-night stay for Medicare unless waived)
  • Surfaces required documents + time-to-place per route
Outputs
What it writes / routes
  • Cockpit disposition card consumes this for primary + alt suggestion
  • Resource matcher uses this for upstream filtering
  • Route choice locks logistics + needs flow
Refresh trigger
When it updates
  • Edits to src/lib/library/routes.ts (e.g. new payer policy)
  • Payer rule updates (e.g. MA plan SNF waiver)
Partners involved:Naviguide (SNF/ARU referral)WellSky CarePort (alt SNF directory)Hospice partners (Mission Hospice, Hospice by the Bay)
Demo data · no PHI · mocked Epic + payer endpoints