Transitions IQ
Care Transitions Software for Hospitals & Health Systems
Transitions IQ gives hospital case managers real-time, cross-facility patient intelligence to improve care transitions from admission through the 30-day readmission window. Start with full context, prioritize the highest-risk patients during the stay, and know the moment a discharged patient returns.
Built for the Full Inpatient Journey:
And What Happens Next
Context at Admission
Prior-encounter history, diagnoses, and post-acute relationships from across 2,800+ hospitals and clinics, surfaced at admission.
Risk That Updates Live
Dynamic Readmission Risk Score trained on 18.3M+ encounters updates throughout the stay so case managers focus where it matters most.
Post-Discharge Visibility
Real-time alerts when a discharged patient is admitted anywhere in the network, within the 30-day HRRP intervention window.
Episode-Cost Readiness
Out-of-network leakage alerts and cross-facility visibility make TEAM and other episode programs manageable with the staff you already have.
Cross-Facility Intelligence Across the Entire Inpatient Journey
Start every admission with the patient’s full network history
Prior-encounter visibility at admission
See where patients have been treated, what was diagnosed, and which post-acute providers they were last connected to across 2,800+ hospitals, 3,600+ clinics, and 27,000+ LTPAC providers. Discharge planning starts with full context, not gaps filled by patient self-reporting.
Network-wide diagnoses and history
Pull recent encounter data from across the largest acute + post-acute network in the U.S. so care teams can avoid duplicative testing and surface clinical context the EHR alone can’t see.
Post-acute relationships already mapped
Know which SNFs, home health, and other post-acute providers the patient has worked with so discharge planning aligns with established care pathways from day one.
Surface the highest-risk patients before they’re discharged
Dynamic Readmission Risk Score
A machine learning model trained on 18.3M+ encounters scores each inpatient’s readmission risk in real time and updates as new ADT events arrive, outperforming static, admission-only LACE-based scoring.
Inpatient Activity page with LOS visibility
See every active inpatient stay with risk scores, length-of-stay, and discharge readiness signals — filterable to surface patients approaching target LOS or flagged as high readmission risk.
Prioritize where capacity goes
Stop spreading case management capacity evenly across every discharge. Concentrate higher-touch follow-up on the patients most likely to come back.
Know when discharged patients come back—anywhere in the network
Real-time post-discharge ADT alerts
Get notified the moment a recently discharged patient is admitted, transferred, or discharged at any of 2,800+ hospitals or 3,600+ clinics, delivered via your preferred channel within the 30-day HRRP window when intervention still matters.
Out-of-network leakage visibility
See readmissions at competitor facilities your EHR can’t. 95% of U.S. hospitals discharging to SNFs are in the PCC network, so coverage reaches where leakage actually happens.
HRRP and TEAM model readiness
Quantify and prevent readmission penalty exposure with real-time data, and manage TEAM episode accountability for CABG, joint replacement, spinal fusion, and surgical hip fracture without adding headcount.
Start every admission with the patient’s full network history
Prior-encounter visibility at admission
See where patients have been treated, what was diagnosed, and which post-acute providers they were last connected to across 2,800+ hospitals, 3,600+ clinics, and 27,000+ LTPAC providers. Discharge planning starts with full context, not gaps filled by patient self-reporting.
Network-wide diagnoses and history
Pull recent encounter data from across the largest acute + post-acute network in the U.S. so care teams can avoid duplicative testing and surface clinical context the EHR alone can’t see.
Post-acute relationships already mapped
Know which SNFs, home health, and other post-acute providers the patient has worked with so discharge planning aligns with established care pathways from day one.
Surface the highest-risk patients before they’re discharged
Dynamic Readmission Risk Score
A machine learning model trained on 18.3M+ encounters scores each inpatient’s readmission risk in real time and updates as new ADT events arrive, outperforming static, admission-only LACE-based scoring.
Inpatient Activity page with LOS visibility
See every active inpatient stay with risk scores, length-of-stay, and discharge readiness signals — filterable to surface patients approaching target LOS or flagged as high readmission risk.
Prioritize where capacity goes
Stop spreading case management capacity evenly across every discharge. Concentrate higher-touch follow-up on the patients most likely to come back.
Know when discharged patients come back—anywhere in the network
Real-time post-discharge ADT alerts
Get notified the moment a recently discharged patient is admitted, transferred, or discharged at any of 2,800+ hospitals or 3,600+ clinics, delivered via your preferred channel within the 30-day HRRP window when intervention still matters.
Out-of-network leakage visibility
See readmissions at competitor facilities your EHR can’t. 95% of U.S. hospitals discharging to SNFs are in the PCC network, so coverage reaches where leakage actually happens.
HRRP and TEAM model readiness
Quantify and prevent readmission penalty exposure with real-time data, and manage TEAM episode accountability for CABG, joint replacement, spinal fusion, and surgical hip fracture without adding headcount.
Start the Conversation
Book a live demonstration to see how Transitions IQ can help your hospital reduce readmissions, prevent HRRP penalties, and prepare for TEAM model accountability.
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Frequently Asked Questions
EHR-native alerts only surface readmissions within your own health system. When a discharged patient goes to a competitor hospital, your EHR has no visibility. The PCC network covers 2,800+ hospitals—including the facilities your patients are actually going to when they don’t come back to you.
Other solutions primarily push ADT event data to your case management team. Transitions IQ adds real-time clinical context, a Readmission Risk Score trained on 18.3M+ encounters, and the largest post-acute network in the U.S., not just ADT pings.
A single prevented readmission in a high-penalty condition like heart failure or AMI frequently exceeds the monthly contract cost.
TEAM (mandatory in 2026) creates bundled episode accountability for CABG, joint replacement, spinal fusion, and surgical hip fracture—conditions where post-discharge readmissions hit hardest. Transitions IQ provides the cross-facility, real-time encounter visibility that makes episode accountability manageable without adding headcount.
Lightweight—a patient feed from your EHR plus configuration of alert preferences. Most hospitals are live within weeks of feed configuration.
Start the Conversation
Request a demo of Transitions IQ and see the difference real-time care collaboration can make for your hospital.