CareMax cuts facility discharges by one in six with early mobilization
CareMax is a physician-led ACO caring for Medicare members. At a 140-bed Massachusetts hospital, its Transition Liaison paired Radial Care, which flags on the first day of a stay the patients at risk of an unnecessary facility discharge, with an early mobilization program run by the whole care team. More of those patients went home, and readmissions held steady.
1 in 6 fewer discharges to skilled nursing and rehab facilities
Readmissions held steady after adjusting for case mix
Flagged on day 0 or day 1 of the hospital stay
The challenge: too many patients leave the hospital for a facility
For Medicare members, a discharge to a skilled nursing facility (SNF) often means a longer recovery, deconditioning, and a higher risk of an unplanned readmission. Many patients, especially those with chronic illness and social risk factors, could recover better at home. But knowing which patients are suited to a home discharge, and making that transition seamless, is hard.
Sue Horton, RN, CCM, CHC, a CareMax Transition Liaison, saw these challenges firsthand. She knew from the literature that getting patients moving early in a hospital stay reduces deconditioning and makes a discharge home more likely. She also knew that strong teamwork across the care team would be critical to preventing unnecessary discharges to SNFs and inpatient rehab facilities (IRFs).
The solution: Radial Care flags the patients to get moving on day one
Sue designed and led an early mobilization initiative at a 140-bed acute care hospital in Massachusetts, with Radial Care at its center. Radial Care's Placement module uses AI to find the hospitalized CareMax Medicare members at high risk of an unnecessary facility discharge, the ones most likely to benefit from early mobilization and a home-first discharge plan. It flags them on day 0 or day 1 of the hospital stay, giving the care team time to act.
Four ways the care team got patients moving
Physical therapy, occupational therapy, case management and nursing all took part.
- 1
Clear communication
Physical and occupational therapists wrote specific mobilization recommendations into their progress notes, such as "out of bed to chair three times daily", and the orders went up on the whiteboard in each patient's room so nursing staff could see them.
- 2
A chair in every room
CareMax confirmed that every patient room had a suitable chair, so patients could get up as soon as they were medically cleared.
- 3
Daily coordination
Patients flagged by Radial Care were discussed at multidisciplinary rounds and daily huddles, so the whole care team worked to the same plan.
- 4
Nurses in the lead
Nurses and nursing assistants were trained to carry out mobilization plans, and encouraged to spot barriers to mobilization and work directly with physical and occupational therapists.
The results: one in six fewer facility discharges
Among the hospitalized CareMax Medicare members that Radial Care prioritized, discharges to a SNF or IRF fell from 23% before the initiative to 19% with early mobilization.
- Discharges to post-acute facilities fell by one in six, as patients were found and mobilized earlier.
- Readmissions held steady after adjusting for case mix, confirming that the discharge plans were safe and appropriate.
- Patients reported higher satisfaction with their care transitions, citing clear communication and early mobilization.
- Before the initiative
- 23%
- With early mobilization
- 19%
One patient's path home
Radial Care flagged a high-risk CareMax Medicare member on day 1 of the hospital stay. The Transition Liaison built agreement on the physical therapist's documented recommendation that the patient be out of bed for meals and for every assessment. Physical therapists went over the mobilization goals with the nursing staff, and the Transition Liaison reviewed the plan with the floor RN case managers. The patient got moving early and went home with the right services, avoiding an unnecessary stay in a SNF or IRF.
"Using Radial Care's data intelligence to identify the 'on the border' patients for intervention proved to be an essential component of our early mobilization initiative."
A home-first culture
The program did more than improve outcomes: it changed how the hospital plans discharges. Early mobilization became a shared goal across disciplines, building teamwork among care teams and making home first part of the hospital's culture.
What's next
The initiative is part of CareMax's broader strategy to reimagine care transitions around patient-centered, home-first approaches. Its success shows that early mobilization works, and that these practices can scale to every hospital that serves CareMax Medicare members. With Radial Care's insights in the hands of its care management teams, CareMax is setting a new standard for physician-led organizations managing total population risk.
Read the full case study
With thanks to Sue Horton, RN, CCM, CHC, Karen Warren, RN, MSN, CPHQ, and Liza Ferguson, RN (CareMax), with Kerry Son, MSN, FNP-BC, Matt Wilson, DPT, and Emily Huang (Radial).
A partner, not a portal
Find the patients who could go home, and get them moving on day one.
Bring one question about your population. We'll show you the platform on illustrative data, then size the opportunity on yours, with the team who would work beside you.
- A named clinical and technical lead
- Quarterly business reviews
- On-site visits and training