Episodes (or Billing Episodes)
A billing episode is a single billing instance of a certain type of care. An episode can occur for any claim that has a start and an end date. These claims are institutional claims that take place in, or associated with, a facility (eg. Hospitals, SNFs, HHA, Hospice). The period from the start of care to the discharge date would be considered an episode of care. A patient can have multiple episodes of care and can have contiguous episodes of care.
Episodes are typically used in the Trella Health Solutions to determine the “carepath” of the patient. They are also used to calculate performance metrics, as each episode typically presents as an opportunity for an event to have occurred. For example, each hospital episode has the opportunity for a readmit to occur if the same patient is admitted within 30 days of the discharge date.
Note: Physician claims are billed for a single date and thus are not considered an episode.
A stay is (potentially) multiple billing episodes that are contiguous and occur without interruption. Stays are used to determine the length of time a patient stays in Home Health or Hospice care. By joining multiple billing episodes together, we use the start of care date for the first episode and the discharge date for the last episode to determine the start date and discharge date for the stay.
It is important to note a difference between Hospice and Home Health metrics with regard to stays. On the hospice side, Average Lengths of Stay (ALOS and MLOS) can include periods of any length from admission to discharge. On the Home Health side, because of the centrality of the Home Health Episode, all "length of stay" metrics are averaged against episodes, that is, the metric is Average Days per Episode." We do "stitch together" multiple episodes into a stay for calculating % Hospitalization and % Readmission metrics.
Patients are counted by determining the number of unique beneficiaries that get care for a period. The patients are determined by using the beneficiary ID on the episode. Thus, for each episode that occurs during the period, we count the unique number of patients.
For example, if a beneficiary had two hospital stays during a quarter, and the measure was a count of patients, the count would be only 1 patient.
What is a “carepath?”
A “carepath” is the route a patient takes from one care setting to the next. These are created by tracking one beneficiary ID through multiple episodes to determine the various providers that treated the patient over a period. Since these episodes are not typically contiguous, “windows” of time can be used to associate two episodes together when there is a break between one episode and the next.
For example, one type of “carepath” in the Trella Health Solution is used to infer referrals from a hospital to a Home Health or Hospice agency. In this case, a hospital episode is used as the start of the “carepath”. Then, for the same beneficiary, if a Home Health or Hospice episode takes place within 30 days of the hospital episode, this is considered a referral. Thus, this is a “carepath” from a hospital to a Home Health or Hospice agency.