Bundle Patient Worksheet

The ACO Bundle Patient Tracker is a comprehensive interdisciplinary workflow and discharge planning tool designed specifically for skilled nursing facilities managing CJR, TEAM, ACO, bundled payment, and other value-based care patients. This structured tracker helps facilities maintain heightened oversight of patient progress, discharge barriers, caregiver readiness, and interdisciplinary coordination throughout the entire stay.

Built for MDS, therapy, nursing, social services, and UR teams, this tool helps facilities proactively manage patients requiring focused discharge planning, rapid functional progression, reduced length of stay, and successful transition to lower levels of care. The format is designed to facilitate weekly UR and discharge planning discussions while keeping all disciplines aligned on patient goals, risks, and next steps.

Designed by clinical reimbursement and post-acute care professionals, this tracker helps support stronger communication between departments, earlier identification of discharge barriers, improved care coordination, and more organized bundled-payment management workflows. Ideal for facilities focused on reducing rehospitalizations, improving functional outcomes, strengthening discharge efficiency, and supporting successful transitions back to the community.