Transitions of Care (TRC)
Operated by a national health plan on the 1health platform. The same episode is worked by the plan, the primary care practice, and, next, the discharging hospital.
Automate the high-friction period when a patient moves from the hospital to primary care, ensuring follow-up occurs and quality gaps are closed.
40,000-50,000 patients
1-2 to 4-5 Stars
The Objective
Automate the high-friction period when a patient moves from the hospital to primary care, ensuring follow-up occurs and quality gaps are closed.
Built on 1health
This application is composed from 1health protocols, services, and modules. The mapping below shows how each app capability is enabled by platform pieces.
ADT Ingestion
Admission, Discharge, and Transfer events from hospitals, processed within a day.
Shared Ledger
Longitudinal, auditor-approved record where discharge data is committed for payer review. Cross-organizational by design.
TCM Billing
Auto-documentation for Transitional Care Management (TCM) codes.
Notifications
Multi-channel alerts to providers via fax, Direct secure messaging, or email.
App Capabilities
Real-time discharge alerts
Follow-up appointment tracking
TCM code documentation
Provider notification
1health Platform Pieces
| App Capability | Enabled By |
|---|---|
| Real-time discharge alerts | ADT Ingestion (service), Shared Ledger (protocol) |
| Follow-up appointment tracking | Shared Ledger (protocol), Notifications (module) |
| TCM code documentation | TCM Billing (service), Shared Ledger (protocol) |
| Provider notification | Notifications (module), ADT Ingestion (service) |
Three parties, one record
A transition of care has three parties: the hospital that discharges, the health plan that is accountable for the HEDIS Transitions of Care measure, and the primary care practice that has to reach the patient, reconcile medications, and see the patient inside the TCM window. On 1health they work the same episode on the same record.
Transitions of Care
The plan sends 1health an event when a member is admitted or discharged. 1health identifies the attributed primary care provider, notifies the practice through its preferred channel, commits the discharge record to the shared chart, and tracks the episode to completion for HEDIS evidence. Coordinators collect discharge records and track medication reconciliation. The plan sees every office it reached, which registered, and which are active.
Primary Care Streams
Primary Care Streams is the workspace the practice works in. A discharge opens a transitional care episode automatically. The two-business-day interactive contact clock starts. Medication reconciliation and the face-to-face visit are tracked against TCM deadlines: 7 days for CPT 99496, 14 days for CPT 99495. When every requirement is met, the episode is flagged billing-ready at the right CPT level. Practices join through an invitation that arrives with the plan's notification. It reaches one in five primary care practices in the United States through three Blues plans, with 229,000+ admission and discharge notifications processed.
PanelMD
PanelMD is the free login a provider office uses for everything sent to it from outside the clinic. An office claims its NPI once, signs its own BAA, and every program a plan, hospital, or network sends it lands behind that login. Transitions of Care is the first program delivered this way. Health plans and ACOs get a branded console that shows which offices were reached, registered, and are active.
Next: Discharge Care Streams, the hospital side. A hospital sees where its discharges landed, which practices picked them up, 30-day returns, and the referrals that come back. In development.
How the episode moves
- A hospital event arrives from the plan and opens an episode for that member.
- 1health finds the attributed primary care provider in the directory.
- The practice is notified by fax, Direct secure messaging, or email. The notice carries a link and a PIN; the discharge record is attached once the office registers.
- The practice logs the interactive contact, reconciles medications, and completes the visit inside the TCM window.
- The episode closes on the shared record. The plan has its evidence; the practice has a billing-ready encounter.
Outcomes
4-5 Stars
Medicare Advantage rating lift within 6 months
300,000+
Critical care gaps closed annually
$200-$300+
New PCP revenue per discharge via TCM
3.3x
100-person team scaled from 90K to 300K annual units
Build Without vs. With 1health
Build Without 1health
- Estimated Timeline: 18-24 months for initial build
- Requires building custom ADT parsers for hundreds of hospital feeds
- Achieving NCQA/SOC 2 Type II/HIPAA compliance for data storage
- Creating 1:1 integrations with dozens of EHRs
The 1health Advantage
- Launch in weeks using MCP APIs for ADT data
- Leverage 1health's existing Auditor-Approved data model
- Pre-built hospital feed integrations
- Compliance infrastructure included
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