business model, business model canvas, mission model, mission model canvas, customer development, lean launchpad, lean startup, stanford, startup, steve blank, entrepreneurship, I-Corps, Stanford

1. CareMatch
SNF-at-Home for Wound
Care
Gurjeet
Singh
Mentor
Monica
Liu
Picker
MD/MBA
James
Vancel
Hustler
MBA
Louis
Blankemeier
Hacker
PhD/MS EE
Pooja
Pradhan
Designer
MBA
95 total interviews
AI to Match Patients to
Post-Acute Care
Post-Acute Care (PAC)
facilities focus on helping
patients recover after
hospitalization
Skilled Nursing Facilities (SNF)
are a type of Post-Acute Care
facility

2. Providers
Medical Groups
Hospitals
Physician Clinics
Payers
Center for Medicare &
Medicaid Services
Commercial Insurance
PACs
Home Health
Skilled Nursing Facilities
Rehab Centers
Long-term Acute Care
First, let’s step back and understand the major roles in the US
healthcare system.
Patients

3. Providers
Clinical Authority
Payers
Financial Authority
PACs
Operational Authority
By interviewing and mapping out stakeholders, we could
understand the relative power each actor held in the system.
Patients

4. We noticed that many patients were experiencing delays in the
last step of the referrals process, costing the healthcare system
upwards of $80 billion every year.1
1 - Estimates put discharge delays = 8.8% of total hospital spending x 2017 total hospital spending estimates of $1.1 trillion = $88 billion.

5. CareMatch V1
AI to Match Patients to
Post-Acute Care Facilities
CareMatch is a predictive algorithm that
streamlines the referrals process for patients from
hospitals to post-acute care facilities.
CareMatch helps hospitals decrease length of
stay, decrease costs, and improve patient
outcomes.
Using predictive
tools to reduce
hospital
readmissions
Standardizing
data flows
Improving a
clunky referrals
process
And thus, CareMatch V1 was born.

6. Initial
Research
Our first findings from the field

7. We sought to find out what causes the delay
in the referrals process
Clunky referrals process
Week 1 Hypotheses
Non-standardized data
Inability to predict best match facility

8. Who we spoke to and why
Weeks 2-3
10 Case Managers (CMs)
To understand how CMs
facilitate the referrals
process to SNFs
8 PAC Admissions Members
To understand what PAC
Admissions are looking for
when they receive a referral
3 Stanford Physicians
To understand the
physician’s role in the
referrals process
Stakeholders in the referrals process

9. Hospital Discharge Process
IT’S COMPLICATED!
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

10. “Biggest delay seen is due to medical complexity,
followed by insurance pre-authorization.”
Insurance authorization is the bottleneck because
insurers don’t want patients to go to facilities.
Case Manager @ Stanford Health Care
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
“I will always reject a PAC referral if I think a patient
could heal at home with a few extra days in the hospital”
Insurance Director

11. Providers
Believe payers blindly
reject care plans and put
patient recovery at risk.
Payers
Believe facilities
overcharge and
unnecessarily retain
patients.
Facilities
Reject patients that they
believe are too complex
from providers.
Patients caught in crossfire: payors don't want pay for PACs
and hospitals don’t feel like home is safe
Patients

12. Pivot
SNF-at-home

13. Original Solution
A SNF-at-home service that helps
higher acuity patients transition to
home health safely.
We focused on re-aligning incentives between payers
and hospitals.
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
A predictive algorithm using
EHR data to best match
patients to post-acute care
facilities.
Revised Solution

14. We examined SNF-at-home through: unit economics,
customer satisfaction, and clinical outcomes.
Is it cost effective?
Board Member @ Payer &
UnitedHealth MA plan
Director of Population
Health @Medical Group
PTs, OTs, Nurses, MDs, Case
Managers
Who cares? Will quality of care be
maintained?
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
Economics Customer Clinical
Who we
talked to:
Who we
talked to:
Who we
talked to:

15. Home Health is significantly cheaper.
Cost per Skilled Nursing Facility
Stay
~$8,000
Cost per Home Care Episode
$2,732
“We would never want to send
patients to PACs. We always
prefer home care.”
– Payor
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
vs.

16. We identified providers (medical groups) who own risk
as our customers.
Providers
Medical Groups
Hospitals
Physician Clinics
Payors
Center for Medicare &
Medicaid Services
Commercial Insurance
Facilities
Home Health
Skilled Nursing Facilities
Rehab Centers
Long-term Acute Care
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
Patients

17. Medical Groups aim to decrease readmissions rates &
maintain patients’ health
“We own patient’s care from hospital to
home” – VP Population Health at a Medical Group
“Value-based providers have huge interest in
optimizing the process as it saves money and improves
quality of care...30 day readmission rate is the most
important figure” – CMO
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

18. Roadblock: “Patients go to SNFs because they need
more hours of care” - PT
PT
OT
Speech
ADLs
Wound
IV Abx
Catheters
Meds
DME
Ostomy
1-2
hrs/week
for all
services
1 hr/day
for most
services
24/7
nursing
care
Home
Health
Skilled Nursing
Facility
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

19. There’s no way to increase hours of care but there is a
way to increase level of care
Post-Acute
Care
Focus on
rehabilitation
LTAC
SNF
Rehab
HH
Level
of
Care
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

20. Skilled Staff suggested telehealth and just-in-time visits to
supplement
Triage Monitor Telehealth
“Can triage
patients for
outreach”
– Senior Manager, Medicare
Strategy
“Home Health used
monitoring for patients
with long-term needs”
– VP Population Health
“Can teach and
watch a patient to do
infusions via
telehealth”
– VP Population Health
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

21. Final Weeks
Finding a beachhead to build an MVP
around

22. Who we spoke to and why
Weeks 7-8
Director of Population
Health @ Desert Oasis
Medical Group
Home Health CEO 2 Physical Therapists 4 MDs
Wound Care Specialist Transitional Care
Manager
Project Manager Occupational Therapist
To better understand which patient indications can be moved into the
home and offers the largest patient population

23. “Wound care is going to be the place to start [in terms of
number of patients impacted].”
Refined patients to those at risk of developing
infections from poor wound management
Director of Population Health
“Having wound care specialists on hand has been
particularly helpful for us in our home health arm.”
VP, Population Health at Medical Group
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
“Wound care makes up around 30-35% of our patient
population.”
CEO, Home Health Agency

24. There is high potential to use telehealth for
patients with wound care needs.
6%
of unplanned hospitalizations in Home
Health patients were due to wound
infections
$36B
Hospital outpatient wound care market that we could
capture1
Activity Potential for Telehealth In-Home Needs
Dressing Change Low
● Wound nurse
● Dressing/Medications
● Wound Vac (DME)
Nutrition and Activity
Adherence
High
● Food that adhere to dietary
needs
● Caregiver to monitor for falls
MD Check-In High
● Telehealth technology
● Camera to view wound
● Ability to measure depth of
wound
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10
1: CMS – Table 4 Medicare spending for wound care by type of service in 2014 by wound type

25. MVP
SNF-at-Home for wound care
patients

26. Three pillars of our MVP
Proprietary algorithm that evaluates
patient risk.
Predict risk level of
patients under home
health using EHR data.
Deploy remote vital trackers, call
center staff, and image capture app
to provide further data collection.
Deploy added data
collection on high risk
patients. If conditions deteriorate, act as a
telehealth on demand with specialists
to review the condition and advise on
care intervention.
Connect to supporting
services on demand.

27. MVP
Algorithm predicts risk
of readmission
Enables us to stratify patients and
schedule provider routes
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

28. MVP
Provider Dashboard &
Patient Details
Allows providers to manage patients
based on risk profiles and readmission
probabilities.
Click here
and get
taken
individual
patient
dashboard

29. MVP
Management View
Tracks key metrics for Medical Groups
on an aggregate level
Start Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10

30. Key Partners
• Wound Clinics
• Home health
agencies
Key Activities
1. Predictive algorithm to
identify patients at
highest risk for
readmissions
2. Technology package to
monitor patients
3. Alert system to dispatch
skilled staf
Value
Propositions
Problem 1: Lack of
skilled staff hours
available to HH
agencies to provide
consistent care
Solution 1: Provide
telehealth +
continuous
monitoring to increase
access/touch points
with skilled staff to
improve patient
outcomes and lower
costs + increase
efficiency of care
Customer
Relationships
• Provide data
analytics and insights
into how process has
improved cost savings,
readmissions rates etc.
Channels
• B2B: 1-sided market
- cost sharing
with Medical
Groups
Customer
Segments
• Population Health
Directors at Medical
Groups
• Independent PT, OT,
Caregiver, Medical
Aide practices
Key Resources
• AI Predictive
Algorithm
• Call Center
• Telehealth platform
• Remote patient
monitoring
Cost Structure
• Development and maintenance of tech infrastructure
• CareMatch team and contractor salaries
Revenue Streams
• SaaS for value-based care providers
Key Activities
Predict patients with
highest risk of
readmissions
Monitor patients
with technology
Connect to
Supporting Services
on Demand
Value
Proposition
Decrease
readmissions
Decrease costs
Increase efficiency
of care
Customer
Population Health
Directors at
Medical Groups

31. What’s Next
How we plan to take CareMatch forward post-LLP
Pilot Program in Wound
Care
Proof of Concept with
Medical Groups
Secure External
Financing
Scale with more Medical
Groups
Monica Liu
MD/MBA
monicaml@stanford.edu
Louis Blankemeier
PhD/MS EE
lblankem@stanford.edu
Leading CareMatch Forward