Transitions of Care (TRC)
Operated by a national health plan on the 1health platform.
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
Real-time processing of Admission, Discharge, and Transfer feeds from hospitals.
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 DSM, fax, and secure messaging.
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) |
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/SOC2/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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