For Emergency Medicine
Closing the loop after the emergency department visit
Capillary Health is the dispatch and routing layer for hospital-at-home programs and home-based care teams. For emergency physicians and ED informaticists, it is the operational infrastructure that turns a positive social or clinical screen into a visit that actually happens.
The last-mile gap
Emergency departments now screen for social needs, document them with structured terminology, and place referrals to community resources. The tooling on the screening side has matured. The tooling on the response side has not.
A positive screen for food insecurity, fall risk, or medication management is supposed to trigger something. In most programs, it triggers a printed handout, a phone number, or a follow-up appointment that may or may not happen. The published evidence on what fraction of ED-based social referrals actually reach a connected service is thin, and the working assumption in most programs is that completion rates are low.
The same gap exists for clinical home-based care from the ED. Hospital-at-home admit pathways, post-discharge nurse visits, IV antibiotic finish-out, and 24-to-72-hour bounce-back checks are real services in many systems, but coordinating who goes where, with what credential, with what equipment, in what order, is a manual process. That manual process is where visits fall through.
Capillary Health is a dispatch engine for the response side. The screen happens in the EHR. The eReferral lands in a community resource platform. The home visit, once it has to actually happen, is what we route.
Three workflows for ED teams
Hospital-at-home admit from the ED
An eligible patient is identified at triage or after evaluation. The ED team admits to hospital-at-home instead of a med-surg bed. Capillary Health receives the service requirements (vitals checks, IV antibiotics, labs, equipment delivery) and assembles a multi-resource visit plan for the next 24 to 72 hours.
SDOH-positive screen with a home-based response
A positive screen for food insecurity, transportation, fall risk, or medication management triggers a home visit from a community health worker, RN, or pharmacy courier. The dispatch engine credentials and routes that visit alongside the program's existing census, with documentation that ties back to the index ED visit.
Bounce-back prevention after high-risk discharge
For patients sent home with a follow-up visit window of 24 to 72 hours, the system schedules and routes the visit, monitors completion, and flags missed visits to the program coordinator. The closed-loop signal flows back to the EHR rather than disappearing into a phone tree.
What the ED actually plugs into
Emergency physicians do not run dispatch. The ED workflow stays the same: screen, document with the right Z-code, place the referral or admit to hospital-at-home through your existing pathway. What changes is what the receiving program has on the other end.
- Multi-resource dispatch (RN, MD, PT, OT, lab, pharmacy courier, equipment delivery) on a single optimized route
- Credential matching so the right clinician sees the right patient
- Continuity scoring that prefers the same clinician across a patient's episode
- Time-window compliance for IV dosing, post-discharge calls, and lab draws
- CSV / XLSX upload for programs without an EHR integration on day one
- HIPAA-compliant: AES-256 encrypted PHI, anonymized solver, full audit log
Operations research basis: Atta et al. (2025), A Concise Review of the Home Health Care Routing and Scheduling Problem, Operations Research Perspectives 15, 100347.
Further reading
Anatomy of a closed-loop referral
What “closed-loop” actually means in operational terms, mapped to USCDI v4, the Gravity Project, and the eReferral implementation guide.
SDOH Z-codes for home-care referrals
Practical mapping of ICD-10 Z55 to Z65 codes to home-based response types, with documentation snippets for the discharge note.
Bring the response side up to the screening side
If you run an ED, a hospital-at-home program, or a community health worker team, we will show you what optimized dispatch looks like with your real schedule data.