Primary Care Streams
Primary Care Streams is a hospital-discharge follow-up app for primary care practices, built by peregrine3.
When a patient is discharged from the hospital, the patient's primary care practice is told, and a transitional care journey opens for that patient: outreach within two business days, medication reconciliation, the follow-up visit, and a billing-ready flag once every requirement is met. The practice works from a shared discharge record instead of a fax or a spreadsheet.
Primary Care Streams is the practice side of the transitions-of-care workflow a national health plan runs on 1health. The plan's admission and discharge events reach the attributed practice through the same patient record. Read the health plan side.
- Who uses it
- Primary care practices and their care teams
- Reach
- One in five U.S. primary care practices, through three Blues plans
- Signup
- Invitation-only for now
The challenge
A primary care practice usually learns that a patient was in the hospital after the fact, from a faxed discharge summary or from the patient at the next visit. By then the transitional care management window has often closed. TCM has fixed deadlines: an interactive contact within two business days of discharge, and a face-to-face visit within seven or fourteen days depending on complexity.
Practices that do the work track it by hand, in spreadsheets and sticky notes, and miss deadlines they did not know were running. The result is care that happens late, and revenue that was earned but never billed.
What the app does
Each block names the platform pieces underneath it.
Step 01: Discharge lands
An ADT or discharge record flows in and opens a transitional care journey for the patient. No manual intake.
- Conduit
- Workflow Builder
- Patient Vault
Step 02: Interactive contact
The two-business-day outreach clock starts. The practice logs the contact and the countdown clears.
- Workflow Builder
- Audit logs
Step 03: Medication reconciliation and follow-up
Records collection, medication reconciliation, and the face-to-face visit are tracked as structured steps against the TCM deadlines.
- Workflow Builder
- Patient Vault
Step 04: Billing-ready
When every requirement is met, the encounter is flagged as eligible at the right CPT level. Nothing is billed that was not done.
- Workflow Builder
- Audit logs
Deadline-aware timelines
Every discharge shows a live countdown for the interactive contact and the follow-up visit, so the practice sees what is due today.
- Workflow Builder
Practice workspace, BAA first
Business Associate terms are accepted before any PHI is shown, and the workspace is scoped to the practice. Practices sign in by invitation.
- One BAA
- Access and consent
- User management and auth
Transformation
Before
- Discharge summaries arrive by fax, or not at all
- The practice hears about the hospital stay at the next visit
- TCM deadlines tracked by hand, in a spreadsheet
- Interactive contact missed because no one knew the clock was running
- Medication reconciliation undocumented
- TCM work done but not billed
With Primary Care Streams
- The discharge opens a journey the same day it happens
- The practice is notified while the patient is still on the way home
- Countdowns for the contact and the visit, per patient
- Contact logged, clock cleared
- Records, med rec, and visit logged as auditable steps
- Encounter flagged billing-ready at the right CPT level
Results
229,000+
Admission and discharge notifications processed
1 in 5
U.S. primary care practices reached
100/ mo
Practices joining every month
$200–300+
New practice revenue per discharge via TCM
Figures from the Transitions of Care deployment on 1health.
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