Real-Time Visibility Across Care Transitions
Claims data arrives too late. Post-acute stays happen out of view. Care managers can’t act until the moment to intervene has already passed.
Care Management Can’t Wait for Claims to Catch Up
Health plans rely on care management to reduce readmissions, control costs, and close quality gaps. But many operate with claims lag, poor visibility into acute encounters and post-acute stays, and limited clinical context for post-discharge outreach. By the time teams can act, the window to intervene has often closed. Real-time data, clinical intelligence, and insight across care settings change that, giving care teams the ability to guide transitions instead of reacting after the fact.
Why care management stays reactive
Claims Data
Lag
Encounters show up in claims weeks after they happen, long after the window to intervene has already closed.
The Post-Acute
Blind Spot
Once members enter skilled nursing or custodial care, visibility disappears where risk and cost concentrate most.
Outreach Without Context
Care managers spend 20+ minutes per case chasing records before they can have an informed conversation with a member.
UM Levers are Narrowing
Prior auth and UM can’t fix what happens between care settings, where avoidable utilization actually gets created.
With PointClickCare, we have access to real-time member data as soon as they are discharged. This empowers our nurses to engage in direct care coordination promptly, affording them additional time to connect with our members swiftly after discharge.
Summer Sweet
Triage and Data Integration Manager, CareOregon
50%
Reduction in readmissions in the first year
3+
Hours saved daily on gathering patient information
Transitions IQ for Real-Time Care Management
Transitions IQ surfaces real-time ADT member encounters as they happen across 2,800+ hospitals and 3,600+ clinics, with risk scoring trained on 18.3M+ encounters. Care teams see who needs them, when, and why, in time to act.
Additional Solutions for Real-Time Care Management
Discharge Intel
Discharge Intel gives care managers the clinical context they need to intervene effectively at the point of post-discharge outreach. AI-powered summaries distill 20+ pages of hospital discharge documentation into medications, diagnoses, follow-up requirements, and barriers to care, delivered within 24 hours of discharge across 2,800+ hospitals and 3,600+ clinics. Outreach starts with informed guidance instead of questions.
Product Capabilities:
AI-powered clinical summaries distill 20+ pages of discharge documentation into what drives outcomes.
Delivered within 24 hours of discharge so care teams can act during the window that prevents readmissions.
EHR-agnostic coverage across 2,800+ hospitals and 3,600+ clinics, no matter which system the facility uses.
Surfaces barriers to care so teams can coordinate SDOH support alongside clinical follow-up.
PAC Management IQ
PAC Management IQ gives health plans real-time clinical visibility during the post-acute stay. Powered by the leading system of record for post-acute care, it addresses the lack of visibility in care management by surfacing live SNF and long-term care clinicals, flagging rising readmission risk, and signaling when a member is ready for the next setting. Plans stop reacting to post-acute stays post-stay, and start managing them as they happen.
Product Capabilities:
Live clinical data from SNF and LTC EHRs during the stay, not claims generated after it.
Identifies members with rising readmission risk while they’re still in the facility.
Flags discharge readiness and next-setting needs so members move home sooner and more safely.
Consolidates post-acute insight across facilities so teams stop chasing records for every stay.
Transitions IQ Network Sponsorship
Transitions IQ Network Sponsorship lets health plans extend real-time encounter visibility and risk intelligence to the providers in their network, turning sponsored providers into an active extension of the plan’s care management strategy. For members the plan can’t reach directly, sponsored providers gain the same visibility and risk scoring the plan would have internally, scaling care management across every sponsored provider’s panel.
Product Capabilities:
Real-time admission, transfer, and discharge notifications delivered to sponsored providers as events happen.
Same dynamic readmission risk scoring the plan uses internally, extended to the provider level.
Scales care management reach across every sponsored provider’s attributed panel.
Aligns network strategy with care management, especially for providers in value-based arrangements.
What PointClickCare customers say
See more customer storiesCareOregon cut readmissions in half in the first year by replacing faxed hospital census reports with real-time encounter data.
L.A. Care achieved 70% time savings in case management outreach and 50% improved outcomes for transitions of care.
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CareOregon cut readmissions in half in the first year by replacing faxed hospital census reports with real-time encounter data.
View customer story
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L.A. Care achieved 70% time savings in case management outreach and 50% improved outcomes for transitions of care.
View customer story
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