A case of post Skilled Nursing Facility (SNF) rehospitalization prevention using CMEC transitional care protocol in a non-compliant patient. This patient underwent right lower extremity major joint replacement and was participating in BPCI Model 3 program with 90-day episode risk sharing. The SNF assumes risk for all services provided within the episode. This includes services provided directly by the SNF and those delivered by other providers including any Part A and Part B services i.e. physician services, DME, services provided by another PAC provider and related acute readmissions.
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