For home health agencies
You can't be in every home every day.
Ziva can help you stay
connected between visits.
Ziva extends your care beyond the visit - continuously monitoring patients through daily check-ins, connected devices, symptom tracking, and intelligent escalation so your team knows who needs attention before the next visit.
Reduces acute-care hospitalisation · Supports PDGM & OASIS documentation · Extends visit capacity · No added windshield time
Program Overview
📅 Overnight
◎
86
Active census
⚑
2
Immediate action
◈
6
Monitor closely
✓
78
Stable
Top conditions flagged
8
Flagged
CHF · 3 (38%)
Post-surgical · 2 (25%)
Wound care · 2 (25%)
Other · 1 (12%)
Census watch
R
Robert K.* · SOC day 12 · CHF
Weight +4.1 lb in 3 days
Y
Yolanda M.* · SOC day 31 · Post-surgical
4 missed doses, new confusion
D
Dorothy · SOC day 19 · Wound care
Temperature rising over weekend
F
Frank D.* · SOC day 47 · Rehab
Vitals stable, gait improving
Isabella
"Robert has gained just over four pounds in three days and reports sleeping upright — a classic fluid-retention pattern for CHF. I've alerted the on-call nurse and asked him to hold today's fluid."
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary.
The gap
Five days a week,
nobody is in the home.
Home health is the most intensive care model outside a facility - and still leaves most of the week uncovered. The clinical events that end an episode in the emergency department almost always develop in that gap.
The unvisited days
A two-visit week means five days without eyes on the patient. Fluid overload, infection and medication errors develop over exactly that horizon.
Acute-care hospitalisation
ACH is the single largest driver of value-based purchasing performance and the most common reason an episode ends badly for everyone.
Capacity and staffing
Clinician shortage plus windshield time caps how many patients an agency can carry. Adding visits isn't an option; adding visibility is.
The continuous care experience
Cover the whole week
without adding a single visit.
The continuous care experience puts a daily presence in the home between clinician visits. Patients feel checked on, families feel informed, and your clinicians walk in with the interval already documented.
01
Vitals from the home
Connected scales, BP cuffs and pulse oximeters transmit automatically, every day including weekends. No manual logging, no app, no patient burden.
02
Symptom check-in
A short daily check-in adds symptoms, pain and mood alongside the readings - no login or smartphone required.
03
Isabella detects the pattern
Weight trajectory, symptom clustering and adherence drift compared to the patient's own post-discharge baseline.
04
Immediate escalation
On-call is alerted with the data, so the response is a targeted visit or a call - not a discovery on the next scheduled day.
05
Visit-ready handoff
Your clinician opens the interval summary in the car: what changed, when, and what the patient reported.
The result is a coverage model that matches the disease timeline rather than the staffing calendar - and a documented record of between-visit monitoring that strengthens your OASIS narrative and your value-based purchasing position.
How Ziva helps
What Ziva actually
puts in place.
Ziva is a service: a connected-device kit and Isabella, an AI care companion, layered onto the days your clinicians aren't in the home. Here's what that means in practice.
Devices
A kit ships to the patient
Ziva orders, ships and sets up a connected scale, BP cuff and pulse oximeter - pre-paired, no Wi-Fi or app setup required from the patient.
Check-ins
Isabella checks in and reminds
Daily conversations capture symptoms, pain and mood, and Isabella reminds the patient to take readings, medications and keep follow-ups - on the days your clinicians aren't scheduled to visit.
Pattern detection
Readings compared to baseline
Isabella watches each patient's own trend line - weight, oxygen, adherence, symptoms - and flags a deviation, not a generic population threshold.
Alert triage
Alerts examined for priority, then routed to you
Every reading and check-in response is reviewed and ranked by urgency before anything reaches your team, so your on-call sees a short, prioritized list to act on - not a raw feed to sort through.
Recovery
Recovery tracked, not assumed
Weight, vitals, symptoms and adherence trending in the right direction across the episode is visible progress - an evidence-based read on who's improving and who needs a closer look.
Documentation
A visit-ready interval summary
What changed, when, and what the patient reported - waiting in the chart before your clinician's next visit, supporting your OASIS narrative.
Isabella monitoring
Watching the days
nobody is in the home.
Isabella builds a personal baseline for every patient from their first few days on service, then watches daily readings and check-in language for a deviation from that baseline - not a one-size-fits-all threshold. A CHF patient's weight climbing alongside reported symptoms is exactly the kind of pattern a twice-weekly visit schedule can miss.
✓Daily weight via connected scale — flagged against the patient's own trend, not a generic cutoff
✓Symptoms captured conversationally — "sleeping upright," "more short of breath" get weighed alongside the numbers
✓Medication adherence via pillbox, tagged to the same timeline as the vitals it affects
✓A converging pattern escalates same-day to your on-call pathway — an isolated reading doesn't
Robert K.* — CHF, SOC day 12, last 3 days
Weight
+4.1 lb
over 3 days
SpO2
96%
within baseline
Reported symptom
Sleeping upright
new, from check-in
Next scheduled visit
4 days out
twice-weekly schedule
Isabella · Today
"Robert has gained 4.1 lb in 3 days and reported sleeping upright last night — the fluid retention pattern that preceded his last CHF admission. Flagged for your on-call nurse, well ahead of his next scheduled visit."
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary.
Impact
Where agencies
see the change.
Every metric that matters to a home health agency runs through the same question: did we know soon enough?
Earlier
Deterioration detection
Weight, oxygen and symptom patterns flagged days before they become an admission
Daily
Patient contact
Isabella checks in every day, including weekends - no added visits
Better
Visit targeting
Send the visit where the data says it's needed, not evenly across the census
Illustrative
Program revenue
Modeled RPM/CCM revenue where a billing physician entity is involved - see below
Directional framing based on Ziva's platform capabilities; results vary by census mix and staffing.
Workflow
How it runs,
day to day.
One continuous operational loop, running in the background between your visits - not a separate system your team manages on top of everything else.
Getting started
Setup, before the loop starts running.
1
Enrol at start of care
The admitting clinician enrols the patient in minutes. Ziva handles device ordering, delivery and setup from there.
2
Connect your EMR
Homecare Homebase, WellSky, Axxess, MatrixCare or your system of record links up so alerts and summaries land where your team already looks.
3
Go live, and continue past discharge
The daily loop above starts immediately. At episode end, monitoring can continue under a physician's RPM/CCM program so the patient isn't dropped into a gap.
Operationally realistic
No extra windshield time
Coverage expands without a single additional mile driven.
Connected devices, no burden
Scales, BP cuffs and pulse oximeters ship pre-paired and transmit automatically - the patient does nothing but use them.
Works with your EMR
Homecare Homebase, WellSky, Axxess, MatrixCare and others via HL7 FHIR R4 or structured export.
Post-episode continuity
The relationship with the patient doesn't end at discharge - which matters for referral relationships and readmission exposure.
Proof
The days between visits,
covered.
Conditions covered
The diagnoses driving your census.
Condition-specific monitoring protocols run automatically based on the patient's diagnoses.
Reimbursement
Reimbursement, capacity
and episode margin.
Agencies benefit on two fronts: value-based purchasing performance tied to hospitalisation rates, and - where the agency operates or partners with a billing physician entity - RPM and CCM revenue on the same population.
RPM — 99453 / 99454 / 99457 / 99458
Device-based physiologic monitoring, 16+ transmission days per month
99453One-time setup & patient education — ~$19
99454Device supply + daily transmission — ~$46/mo
99457First 20 min interactive care management — ~$48
99458Each additional 20 min — ~$39
CCM — 99490 / 99439
Patients with two or more chronic conditions expected to last 12+ months
99490First 20 min clinical staff time / month — ~$62
99439Each additional 20 min — ~$47 (up to 2×)
Where the value shows up
Beyond direct fee-for-service billing
HHVBPAcute-care hospitalisation and ED-use measures directly affect your payment adjustment
Episode marginFewer crisis visits and better-targeted utilisation per episode
Referral positionHospitals and ACOs route volume to agencies with demonstrable readmission performance
Ziva's time logs, monitoring records and monthly reports supply the documentation these codes require. Confirm eligibility and rates with your billing team and MAC.
Program revenue estimate
Patients on service
120
10active census600
Program type
Device supply (99454)—
First 20 min (99457)—
Additional 20 min (99458)—
Estimated monthly program revenue
—
— annually
Illustrative national-average estimates. Actual reimbursement varies by MAC, locality, payer mix and documented time.
Get Started
Model it against
your census.
Share your census mix and hospitalisation rate and we'll model coverage, alert volume and the effect on your value-based purchasing measures.
✓Census-level coverage and alert-volume estimate
✓Acute-care hospitalisation impact modelling
✓On-call and triage workflow design
✓Implementation alongside your current EMR — typically 4–8 weeks
Request a 30-minute demo
We'll walk through enrolment, alert configuration, and the revenue model for your practice.
Book my demo →No commitment. We'll follow up within 1–2 business days.
Security & compliance
Built for healthcare.
Trusted by clinical teams.
Ziva was designed from the ground up for clinical environments - not adapted from a consumer app. Every data flow, access control, and integration meets the standards your compliance team requires.
🔒
HIPAA compliant
BAA available. All PHI encrypted in transit and at rest.
✅
End-to-end encrypted
All PHI encrypted in transit and at rest. HL7 FHIR R4 compliant data exchange.
🏥
US data residency
All patient data stored and processed within the United States.
📋
Audit-ready logs
Consent records, access logs, and billing documentation stored and exportable.
Questions
Home health FAQ
No. Ziva covers the days between visits and helps you place visits where they're clinically needed. Agencies typically keep the same visit volume but redistribute it - more intensity for patients showing early deterioration, less for patients tracking stable.
Acute-care hospitalisation and emergency department use are core HHVBP measures. Most admissions from home health follow a multi-day trajectory - weight gain, oxygen decline, symptom escalation, medication lapse - that is visible on daily data well before it becomes acute. Detecting on day two rather than day six is where the reduction comes from.
Alerts route into your existing on-call pathway, with the supporting data attached so the on-call clinician can triage quickly. Isabella also delivers immediate patient-facing guidance and, where the pattern indicates an emergency, instructs the patient to call 911 and notifies your team simultaneously.
Devices ship pre-paired and transmit automatically - the patient does nothing but step on the scale or use the cuff. Check-ins are conversational and can be completed by voice. For patients who need help, family members can be given proxy access.
It can. Post-episode continuity is one of the strongest arguments for the model: the patient moves to a physician-billed RPM or CCM program and stays monitored, which protects both the patient and your readmission exposure on the referral relationship.
Homecare Homebase, WellSky, Axxess, MatrixCare and others via HL7 FHIR R4 or structured export. Where direct integration isn't available, Ziva provides a standalone portal with PDF and CSV export for the clinical record.
Yes. Fully HIPAA compliant, with a BAA available. All PHI is encrypted in transit and at rest, data is stored within the US, and every alert, call and access event is logged for your compliance file.