Resources
Working references for closed-loop home-based care
Practical, citable, source-able references on the standards, codes, and operational concepts that show up when you build a home-based care program. Written for clinicians, informaticists, and program leaders who want to ship.
Closed-loop referrals and standards
What it actually means to close the loop, and the standards that make it possible.
Anatomy of a closed-loop referral
The six stages of a closed-loop referral mapped to USCDI v4 data classes, the Gravity Project FHIR resources, and the HL7 eReferral implementation guide. Where the loop typically breaks.
USCDI SDOH data classes
What certified health IT must support for social determinants: assessments, conditions, goals, and interventions. The standards layer that lets closed-loop SDOH workflows be interoperable across systems.
Screening, documentation, and coding
Practical references for the front-end of the workflow.
SDOH screening instruments: a comparison
Head-to-head reference on AHC-HRSN, PRAPARE, AHC core 10, Hunger Vital Sign, and WE CARE. Domain coverage, item counts, validation context, and when each is the better operational fit.
SDOH Z-codes for home-care referrals
ICD-10 Z55 to Z65 mapped to home-based response types, with documentation snippets for the discharge note. Working reference for ED, hospitalist, and primary care teams.
Programs and operations
What you need to know to operate a hospital-at-home or home-based care program.
Hospital-at-Home and the CMS waiver
The Acute Hospital Care at Home waiver, eligibility criteria, billing codes, and what current policy uncertainty means for new programs.
Hospital-at-Home staffing models
Dedicated, hybrid, and partner-delivered staffing patterns for hospital-at-home programs. Operational tradeoffs and how the dispatch layer fits each model.
Dispatch vs. routing: a working glossary
Plain-language glossary of dispatch, routing, scheduling, sequencing, and credentialing terms as they apply to home-based care logistics.
Building a closed-loop program?
Capillary Health is the dispatch and routing layer for the response side. We talk to ED teams, hospital-at-home programs, home health agencies, and care management groups about what closed-loop looks like in their workflow.