Your Patients Move Across Settings. Your Visibility Doesn’t.
An alert that a patient moved isn’t visibility. Seeing their clinical status across every care setting is what enables you to act.
The Financial Cost of Clinical Blind Spots
ACO care teams are accountable for a population that never stops moving, but the clinical picture that should follow patients rarely does. Most ACOs have ADT alerts, so they know when a patient is admitted, lands in the ED, or enters a SNF. What they lack is the context to act: what’s driving the ED visit, how the patient is progressing, whether they’re ready to go home. Real-time visibility across settings turns notifications into interventions that protect shared savings.
Four Settings Where the Clinical Picture Goes Dark
Hospital and ED Encounters
Attributed patients are admitted or visit the ED, and most ACOs learn through claims weeks later, too late to act.
SNF Admission Handoff
Nearly 70% of ACOs have no clinical represenation in the SNF, so patients enter a high-risk setting with poor visibility.
SNF Stay
A lack of clinical context during the stay lets rising risk go undetected, missing early chances to prevent readmission.
Return Home
Nearly 1 in 4 SNF residents readmit within 30 days, most preventable, when discharge happens without support in place.
“PAC Management IQ gives us real-time visibility into skilled nursing: where our patients are, what’s happening, and who needs attention most. We went from seeing about 50% of our SNF stays to over 95%, which allows us to intervene earlier and support stronger transitions.”
Nicole Massey
Manager of Care Navigation, Tandigm Health
95%+
SNF stay visibility, up from 50%
4%
reduction in readmissions at non-partner facilities
PAC Management IQ: Clinical Visibility Into the SNF Stay
PAC Management IQ turns live SNF clinical data into AI-driven intelligence, predicting readmission risk during the stay and surfacing discharge readiness, so care teams can intervene early and get patients home safely, sooner.
Additional Solutions to Gain Visibility Across Care Settings
Transitions IQ
Transitions IQ closes real-time visibility gaps, showing ACOs where their patients are across every care setting. It captures admissions, transfers, and discharges as they happen and prioritizes patients based on readmission risk, helping care teams focus where intervention matters most. What was once delayed and fragmented becomes immediate, actionable insight.
Product Capabilities:
Real-time alerts notify care teams the moment an attributed patient is admitted, transferred, or discharged
Risk scoring trained on 18.3M+ encounters updates continuously as patients move across care settings
Customizable cohorts by diagnosis, chronic condition, or utilization patterns refresh with live encounter data
Emergency Department IQ
ED IQ gives ACOs and their hospital partners real-time visibility into when and why patients present to the emergency department. Instead of finding out weeks later through claims, care teams can see ED encounters as they happen and act in the moment. What was once an invisible event becomes an opportunity to intervene, coordinate, and prevent avoidable downstream utilization.
Product Capabilities:
Real-time ED alerts notify care teams when attributed patients present, with clinical context on the visit
AI-generated SNF Summary delivers clinical context the moment a recently discharged patient presents in the ED
What PointClickCare customers say
See more customer storiesTriHealth Improved Post-Acute Transitions and Reduced Readmissions by 28% with Real-Time Data
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TriHealth Improved Post-Acute Transitions and Reduced Readmissions by 28% with Real-Time Data
View customer story
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