Technology
A readmission prevention platform.
Every readmission model tells you who is likely to come back. Ours tells you who you can actually do something about.
The platform screens for patients who are both high-risk and responsive to intervention, then guides your team to the action most likely to prevent the readmission — in real time.
Research results
The platform is built on a decade of research into psychosocial risk.
65%
Average reduction in readmissions in Senior and dual-eligible populations, when used within 30 days of an index admission
40%
Reduction in 30-day all-cause readmissions in the Medicaid population
Want the detail behind these numbers?
Request the research summaryWhy it is different
- Measures Psychosocial Determinants of Opportunity, not the standard social determinants that show little relationship to near-term utilization
- Separates high-risk patients from impactable ones, so spend goes where it can change the outcome
- Not a claims or diagnosis-code risk model, and not redundant with your EMR
How it works
- Patients complete a 4-minute screener on their own phone or device, or with a paraprofessional
- The screener identifies who will readmit as accurately as leading risk prediction models, using only psychosocial data and self-reported measures
- Only patients who screen high-risk go on to the risk model, so staff time goes where it is needed
- The platform returns an Alert Guide with risk scores and real-time action items, shareable across the care team
- Administrators see individual and population-level analytics
- HIPAA-compliant, web-based, and configurable to your population
Strategic partners wanted
We are seeking a select group of risk-bearing organizations and strategic partners to support broader deployment and commercialization. Engagement models may include pilot implementations, subscription arrangements, shared-savings structures, and strategic partnerships.