Aging-In-Place Score and Unity Smart Care

See risk before it becomes a readmission, ED visit, or avoidable service disruption—and act decisively.

• Data sources: combines assessments (including OASIS items for home health), diagnoses, medications, vitals, prior utilization, home safety factors, and social needs.

• Predicts and prioritizes: flags risk for decline, falls, wound deterioration, low adherence, and hospitalization; groups clients into intervention tiers.

• Next-best actions: recommends concrete steps like an RN supervisory check, frequency adjustments, medication reconciliation, caregiver skill match, or virtual check-ins.

• Caseload and visit planning: focus scarce clinical time where it will move outcomes and quality scores most.

• Program reporting: show proactive outreach, risk movement over time, and intervention impact to payers and referral partners.

• Transparent and tunable: explainable factors and regular calibration to your population and documentation patterns. Outcome: more proactive care, better outcomes, and smarter allocation of visits and resources across payers and programs.

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The Benefits of Unity Global Care Aging In Place & Predictive Modeling:

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• Increase revenue:

  • Improve HHVBP outcomes and Star Ratings by preventing avoidable ED visits/readmissions.

  • Stabilize clients to extend appropriate service duration and lifetime value (private duty).

  • Optimize visit frequency to avoid LUPAs and align intensity with PDGM risk and goals.

• Decrease cost:

  • Prevent high-cost emergencies and after-hours calls with earlier detection and outreach.

  • Focus clinician time on high-risk clients; reduce unnecessary check-ins for low-risk cases.

  • Lower transportation and overtime by targeting in-person visits with the highest impact.

• Enhance care quality:

  • Combine clinical, functional, social, and environmental factors to predict decline, falls, or hospitalizations.

  • Generate next-best actions (RN check, med review, frequency change, skill match) to guide care plans.

  • Track risk movement over time to confirm interventions are working.

• Compliance support:

  • Document risk stratification and interventions in the record to meet payer care management expectations.

  • Explainable models and governance with audit trails support CMS CoPs and state survey readiness.

  • Aligns with comprehensive assessment and individualized plan-of-care requirements.