Transitions IQ
Reduce Avoidable Readmissions with Real-Time Encounter Intelligence
Transitions IQ connects health plans to real-time acute encounter data and AI-powered risk scoring to identify members at highest risk for readmissions and preventable utilization. That helps teams prioritize outreach sooner, direct care management resources to the right cases, and act before avoidable utilization occurs.
Why Health Plans Choose Transitions IQ
Close the Intervention Gap
Engage members in real‑time moments that matter—when timely outreach can redirect care plans, prevent readmissions, and lower downstream spend.
Prioritize with Precision
Not every alert deserves the same response. AI risk scoring identifies members at highest readmission risk so your team acts on signal, not noise.
Reduce Total Cost of Care
Enable timely intervention post-discharge to stop recurring utilization patterns and preventable readmissions.
See Across Entire Network
Track members across hospitals, clinics, and care settings in a single longitudinal view keeping care teams connected to the full real-time picture.
How Transitions IQ Works: From Encounter to Action
Real-Time Encounter Visibility Across Your Entire Network
Automatic ADT Capture and Eligibility Matching at Scale
Transitions IQ captures real-time admission, discharge, and transfer events across 2,800+ hospitals and 3,600+ clinics, automatically matched to member eligibility, so teams see acute care activity as it happens, without manual lookups, faxes, or claims-lag blind spots.
Identify the Members Most Likely to Drive Avoidable 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 most recent encounter. Scores update dynamically so teams know who to reach first.
Enable Faster, More Informed Coordination with Network Providers
Share Real-Time Member Data to Improve Care Transitions
When teams identify a high risk member in acute care, Transitions IQ provides encounter data, risk context, and history needed to coordinate with hospitals —enabling smarter discharge planning and timely follow-up so members aren’t lost in transition.
Real-Time Encounter Visibility Across Your Entire Network
Automatic ADT Capture and Eligibility Matching at Scale
Transitions IQ captures real-time admission, discharge, and transfer events across 2,800+ hospitals and 3,600+ clinics, automatically matched to member eligibility, so teams see acute care activity as it happens, without manual lookups, faxes, or claims-lag blind spots.
Identify the Members Most Likely to Drive Avoidable 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 most recent encounter. Scores update dynamically so teams know who to reach first.
Enable Faster, More Informed Coordination with Network Providers
Share Real-Time Member Data to Improve Care Transitions
When teams identify a high risk member in acute care, Transitions IQ provides encounter data, risk context, and history needed to coordinate with hospitals —enabling smarter discharge planning and timely follow-up so members aren’t lost in transition.
With PointClickCare, we have access to real-time member data as soon as they are discharged. This eliminates the need for cumbersome back-and-forth exchanges and waiting or census reports to be faxed from hospitals. It empowers our nurses to engage in direct care coordination promptly, affording them additional time to connect with our members swiftly after discharge, even facilitating in-person meetings within the community or at their homes if necessary.
Summer Sweet
Triage and Data Integration Manager, CareOregon
50%
Reduction in readmissions after the first year of implementation
3+ Hours
Saved daily on time spent identifying and gathering patient information
Request a Demo
Book a live demonstration to see how Transitions IQ can help your organization reduce readmissions.
Explore more Health Plan solutions
See all products for Health PlansFrequently Asked Questions
Transitions IQ is not just an ADT feed. It combines real-time encounter capture across 2,800+ hospitals and 3,600+ clinics with a proprietary Readmission Risk Score, customizable population stratification, and longitudinal member records. It delivers prioritized, actionable intelligence enabling care teams to focus on the members and moments that matter most.
The Readmission Risk Score is a proprietary machine-learning model trained on 18.3M+ patient encounters. Unlike the LACE model, Transitions IQ’s score dynamically updates throughout a patient’s stay, incorporates EHR-agnostic input variables including SDOH and behavioral health indicators, and delivers both a score and clinical indicators to guide intervention decisions.
