The admission is the easy part. The transition is where patients fall.
Readmissions within 30 days cost the healthcare system $26 billion annually, and CMS penalizes hospitals for excess readmissions in heart failure, pneumonia, COPD, hip/knee replacement, and coronary artery bypass. As a hospitalist, you manage the acute episode — but in value-based care, your responsibility extends through the discharge and into the outpatient follow-up window.
Glance tracks transitions of care, scores readmission risk at admission, coordinates discharge follow-up, and ensures HCC codes captured during the inpatient stay are communicated back to the primary care team.
Schedule a Demo See FeaturesClose the inpatient-outpatient gap
Value-based care does not stop at the hospital door. Glance extends the hospitalist's view through discharge and into the follow-up window.
Transitions of Care Tracking
Track every discharged patient through the critical 7-day and 30-day windows. See which patients have PCP follow-up scheduled, which are pending, and which have fallen through the cracks. HEDIS TRC measure compliance calculated automatically. Coordinate with the outpatient care team to ensure medication reconciliation and discharge instruction follow-through.
Readmission Risk Scoring
At admission, see the patient's prior utilization history: number of admissions in the last 90 days, ED visits, chronic conditions, medication burden, and social determinants. Risk-stratify your census so discharge planning resources are focused on the patients most likely to bounce back.
Inpatient HCC Capture
Inpatient encounters are rich opportunities for HCC coding. New diagnoses made during hospitalization (new-onset CHF, newly discovered CKD, cancer diagnoses) should be captured and communicated to the outpatient team. Glance tracks HCC-relevant diagnoses from the inpatient claim and ensures they are reflected in the patient's longitudinal record.
Medication Reconciliation
See the patient's full outpatient medication list alongside inpatient changes. Track which medications were added, stopped, or modified during the hospitalization. Flag discrepancies between the discharge medication list and outpatient pharmacy fills. Medication reconciliation is a CMS condition of participation — and a leading cause of readmission when done poorly.
Readmission Cost Analytics
Quantify the financial impact of readmissions on your VBC contract. Track 30-day readmission rates by diagnosis, by attending, and by discharge disposition. Model the savings from reducing readmission rates by 1-2 percentage points. Benchmark against CMS Hospital Readmission Reduction Program targets.
