Transitions IQ
Real-Time Care Coordination and Risk Intelligence Software for ACOs
Transitions IQ connects ACOs to real-time acute encounter data and AI-powered risk scoring to identify attributed patients at highest risk for readmissions and avoidable utilization. That helps care teams act during the episode, focus resources on the right patients, and intervene before costs hit the benchmark.
Why ACOs Choose Transitions IQ
Act in the savings window
Intervene in moments that matter: when timely outreach can prevent readmissions, redirect care, and protect shared savings before claims arrive.
Prioritize with precision
Not every alert deserves the same response. AI risk scoring surfaces the patients most likely to readmit so teams act on signal, not noise.
Reduce cost of care
Prevent readmissions, reduce ED overuse, and avoid extended stays by enabling timely intervention at the point of encounter.
See your whole population
Track attributed patients across settings, even those that go out of network, in one longitudinal view, without having to wait for claims.
How Transitions IQ works: from encounter to action
Real-time encounter visibility across your attributed population
Automatic ADT capture and attribution matching at scale
Transitions IQ captures real-time admission, discharge, and transfer events across 2,800+ hospitals, 3,600+ clinics and 27,000 LTPAC providers, automatically matched to your ACO attribution file—so care teams see acute activity as it happens, without manual lookups, faxes, or claims-lag blind spots.
One longitudinal view of every attributed patient
A centralized ACO portal shows every attributed patient across markets, facilities, and EHRs—with encounter history, risk indicators, latest contact info, and clinical context—so care teams can find and engage transient or hard-to-reach patients who only surface in claims.
Alerts delivered to the workflows your team already uses
Encounter alerts and curated feeds reach care teams via portal, email, text, fax, direct message, or flat file—and flow into the care management systems and data warehouses you already run.
Identify the attributed patients most likely to drive readmissions
AI risk scoring that evolves with every encounter
Proprietary ML model trained on 18.3M+ patient encounters scores readmission risk in real time using visit history, diagnoses, SDOH, and behavioral health signals from the latest encounter. Scores update dynamically so teams know which patients to reach first.
Cohorts built around your ACO programs and risk contracts
Define dynamic cohorts by MSSP eligibility, care management enrollment, chronic conditions, ED rising risk, or behavioral health/SUD. Cohorts update automatically as new encounter data flows in—so the right care manager is alerted the moment a flagged patient hits a facility.
Catch ED rising risk before patterns become chronic
Transitions IQ flags attributed patients with escalating ED use across 30-day, 3-, 6-, and 12-month patterns alongside chronic conditions and behavioral health history, enabling teams to reach out before episodic ED visits harden into a fixed cost on the benchmark.
Coordinate care faster with shared real-time encounter intelligence
Share real-time patient data to improve care transitions
When care teams spot a high-risk patient in acute care, Transitions IQ supplies the encounter data, risk context, and history to coordinate with the providers involved in that patient’s care, enabling smarter follow-up so patients aren’t lost in transition.
Share insights and care recommendations across providers
Share insights, diagnoses, medications, and care recommendations with other providers treating the same attributed patient across the network, regardless of EHR, to prevent duplicative services and avoid the high-cost admissions that erode shared savings.
Structured flags, tags, and scheduled reports for ACO workflows
Surface MSSP eligibility, care management enrollment, chronic conditions, and caseload assignment as structured flags and tags. Deliver daily, weekly, or monthly reports plus ADT feeds into your ACO systems via flat file or curated integration.
Real-time encounter visibility across your attributed population
Automatic ADT capture and attribution matching at scale
Transitions IQ captures real-time admission, discharge, and transfer events across 2,800+ hospitals, 3,600+ clinics and 27,000 LTPAC providers, automatically matched to your ACO attribution file—so care teams see acute activity as it happens, without manual lookups, faxes, or claims-lag blind spots.
One longitudinal view of every attributed patient
A centralized ACO portal shows every attributed patient across markets, facilities, and EHRs—with encounter history, risk indicators, latest contact info, and clinical context—so care teams can find and engage transient or hard-to-reach patients who only surface in claims.
Alerts delivered to the workflows your team already uses
Encounter alerts and curated feeds reach care teams via portal, email, text, fax, direct message, or flat file—and flow into the care management systems and data warehouses you already run.
Identify the attributed patients most likely to drive readmissions
AI risk scoring that evolves with every encounter
Proprietary ML model trained on 18.3M+ patient encounters scores readmission risk in real time using visit history, diagnoses, SDOH, and behavioral health signals from the latest encounter. Scores update dynamically so teams know which patients to reach first.
Cohorts built around your ACO programs and risk contracts
Define dynamic cohorts by MSSP eligibility, care management enrollment, chronic conditions, ED rising risk, or behavioral health/SUD. Cohorts update automatically as new encounter data flows in—so the right care manager is alerted the moment a flagged patient hits a facility.
Catch ED rising risk before patterns become chronic
Transitions IQ flags attributed patients with escalating ED use across 30-day, 3-, 6-, and 12-month patterns alongside chronic conditions and behavioral health history, enabling teams to reach out before episodic ED visits harden into a fixed cost on the benchmark.
Coordinate care faster with shared real-time encounter intelligence
Share real-time patient data to improve care transitions
When care teams spot a high-risk patient in acute care, Transitions IQ supplies the encounter data, risk context, and history to coordinate with the providers involved in that patient’s care, enabling smarter follow-up so patients aren’t lost in transition.
Share insights and care recommendations across providers
Share insights, diagnoses, medications, and care recommendations with other providers treating the same attributed patient across the network, regardless of EHR, to prevent duplicative services and avoid the high-cost admissions that erode shared savings.
Structured flags, tags, and scheduled reports for ACO workflows
Surface MSSP eligibility, care management enrollment, chronic conditions, and caseload assignment as structured flags and tags. Deliver daily, weekly, or monthly reports plus ADT feeds into your ACO systems via flat file or curated integration.
“(Transitions IQ) really helps us know where our population is. Without it, I feel like we would be kind of lost.”
Jenny Gonnerman
Director of Clinical Operations, PSW
11%
reduction in avoidable ED visits
62.5%
successful engagement rate for post-ED outreach
Proven Impact with Transitions IQ
See more customer storiesClinically Integrated Network Improves Care Coordination
Request a Demo
Book a live demonstration to see how Transitions IQ helps ACOs intervene in real time, reduce readmissions, and protect shared savings.
Explore More ACO Solutions
See more products for ACOsFrequently Asked Questions
Via attribution files provided by the ACO on a monthly cadence (or more frequently) through secure SFTP. Files are matched in real time against incoming ADT events across the PCC network.
Transitions IQ is EHR-agnostic, pulling encounter data from 2,800+ hospitals, 3,600+ clinics and 27,000+ LTPAC providers regardless of their EHR. Alerts and data flow into your existing workflows via portal, email, text, fax, direct message, flat files, and curated ADT feeds.
EHR query tools require you to know a patient is at a facility and pull their record one at a time. Transitions IQ pushes real-time encounter alerts and risk scores to your care team the moment an attributed patient presents at any of 2,800+ hospitals, across every major EHR, with cohort logic, risk stratification, and longitudinal context layered on top.
Our proprietary score is trained on 18.3M+ patient encounters and outperforms LACE in predictive accuracy. Unlike static scores generated at admission or from historical claims, it updates dynamically throughout a patient’s stay using 12-month visit history, diagnoses, SDOH, behavioral health indicators, and hospital quality scores.
Real-time encounter visibility powers workflows behind Transitions of Care (TOC), all-cause readmissions, ED utilization, and care coordination measures. By surfacing attributed patients during the episode and the 30-day post-discharge window, Transitions IQ lets care teams act in time to influence the benchmark, not after it closes.
Take a Closer Look
Request a demo of Transitions IQ and see the difference real-time ACO care coordination can make for your shared savings performance.