Post-Discharge Intelligence for SNFs

Close the gap
after discharge.

TCIQ equips skilled nursing facilities with AI-powered post-discharge outreach, structured discharge education workflows, and VBP analytics — built on PointClickCare FHIR.

Request Early Access → See the Platform
TCIQ · Discharge Queue PCC Live
Pending Education — Today
Margaret T. Sullivan
Age 83 · CHF · Lives alone
High · 87
Dorothy A. Williams
Age 81 · Post-stroke · HH confirmed
High · 79
Harold J. Kowalski
Age 87 · Hip fracture · Daughter local
Med · 54
VBP Performance — This Month
17.2%
Readmission Rate
91%
Education Complete
88%
AI Follow-up Rate
$31.6K
VBP Exposure
71%
of SNFs penalized under Value-Based Purchasing in 2024
67%
of SNF readmissions are considered preventable
30
day post-discharge window that currently has no technology layer
$0
affordable post-discharge tools available to regional SNF operators today
The Problem

The 30-day window
has no technology layer.

SNFs invest heavily in in-facility care. The moment a resident goes home, the connection breaks — and readmissions follow.

25%
Readmitted within 30 days
One in four SNF patients returns to the hospital within a month of discharge. Most are preventable with timely outreach and early concern detection.
2%
VBP penalty on Medicare revenue
CMS withholds up to 2% of Medicare reimbursement from high-readmission facilities. For a mid-sized building that's $18,000–$40,000 per year at risk.
0
Affordable tools for regional operators
Enterprise readmission solutions require hospital partnerships and deep IT integrations. Small and regional SNF operators have been left without options.
The Platform

Three surfaces.
One connected workflow.

TCIQ connects the social worker at discharge, the AI agent in the field, and leadership in the dashboard — closing the loop that currently doesn't exist.

◈
Social Worker Discharge Workflow
A 6-step education workflow auto-generated from the resident's PointClickCare FHIR record. Diagnoses, medications, warning signs, and family contacts are pre-populated. TCPA consent and outreach preference are captured before the resident leaves.
⟳
AI Post-Discharge Outreach Agent
Automated SMS and voice check-ins at 48 hours, 7 days, and 30 days post-discharge — using the facility's own caller ID to maximize answer rates. Constrained response options ensure clinical data reliability. Concern flags route to the designated escalation contact immediately.
◎
Leadership Analytics Dashboard
VBP exposure, readmission trends, education compliance, and AI follow-up completion rates — at the building level and across the regional network. Role-separated views for DONs and regional operators, with HIPAA audit logging on all resident-level data access.
AI Agent — 48-Hour Check-in · Frank D. Moretti
①
Outreach initiated via SMS
TCIQ AI → Eleanor Moretti (Wife) · (563) 555-0388 · Facility caller ID
②
Daily weigh-in not occurring
"He says the scale is hard to get to." Scale access is critical for CHF monitoring.
⚠ Concern
③
Ankle swelling increased since discharge
"His ankles look puffier since yesterday." Edema progression flagged.
⚠ Concern
④
Shortness of breath with minimal activity
"He got winded going to the bathroom." Dyspnea on exertion — escalation triggered.
🚨 Escalate
✓
Escalation contact notified
3 concerns flagged · DON Maria Torres notified · 10:12 AM
How It Works

From discharge to
30-day follow-up.

A single workflow that requires no new staff hires and adds less than 15 minutes to the social worker's existing discharge process.

Step 01
Discharge Education
An ADT discharge event in PointClickCare triggers the TCIQ social worker workflow. Conditions, medications, warning signs, and emergency contacts are auto-populated from the resident's PCC FHIR record. TCPA consent and family contact preference — SMS, voice, or both — are captured before the resident leaves the building.
Step 02
AI Outreach Agent
TCIQ automatically contacts the family at 48 hours, 7 days, and 30 days post-discharge via the preferred channel. The facility's own phone number is used as caller ID for maximum answer rates. Structured response options ensure reliable clinical data. Concern flags are routed to the designated escalation contact in real time, no polling required.
Step 03
Review and Documentation
Flagged concerns surface in the TCIQ dashboard for clinical review. Staff push a summary note to PointClickCare under their own credentials, maintaining full clinical accountability. The complete audit trail is stored in TCIQ with 6-year HIPAA-compliant retention. Leadership sees readmission trends and VBP performance in real time.
Technical Foundation

Built on PointClickCare FHIR.

TCIQ integrates with PointClickCare via the USCDI Connector FHIR API. ADT discharge events trigger the workflow automatically — no manual data entry, no duplicate charting.

TCIQ is built as a Provider-facing and Bulk SMART on FHIR application targeting the USCDI v1 data set. Infrastructure runs on HIPAA-eligible Microsoft Azure services with database-per-tenant isolation, customer-managed encryption keys, and 6-year audit log retention via Azure Monitor and Log Analytics.

PointClickCare FHIR USCDI Connector SMART on FHIR Microsoft Azure Azure Health Data Services HIPAA Compliant Entra External ID Twilio HITRUST (planned) SOC 2 Type II (planned)
FHIR Resources — USCDI v1 PCC Connector
Patient Demographics, identifiers
RelatedPerson Family contacts, relationships
Condition Active diagnoses, ICD-10 codes
MedicationRequest Discharge medication list
CarePlan Post-discharge care instructions
CareTeam Responsible clinical contacts
Coverage Medicare / payer information
ADT Notifications Discharge event triggers
Early Access

Built for SNF operators ready for what's next.

TCIQ is in active development. We're working with a small group of regional operators to validate the platform before broader release. If you're ready to close the post-discharge gap, reach out.

Request Early Access →
Questions? [email protected]  ·  GoTCIQ.com  ·  Davenport, Iowa