​​Coordinating Post-Acute Care Transitions

A use case showcasing how blueBriX helps providers ensure safe, timely, and connected recovery after discharge

Reduced Readmissions

Patients receive timely follow-ups, clear instructions, and coordinated care—reducing avoidable returns to the hospital.

Faster Care Transition Completion

Automated workflows ensure every post-discharge step – appointments, assessments, and handoffs are executed without delay.

Improved Patient Recovery Experience

Patients feel supported through continuous communication, reminders, and personalized guidance during recovery at home.

blueBriX Post-Acute Coordination Engine: Purpose-Built for Smooth Transitions From Hospital to Home

Problem
Discharge Instructions Are Often Missed or Misunderstood

Patients frequently leave the hospital overwhelmed, leading to poor compliance with medications, follow-up visits, and self-care instructions.

Solution
Personalized Post-Discharge Action Plans

blueBriX auto-generates simplified, patient-friendly discharge summaries and recovery tasks delivered through SMS, email, or portal—ensuring patients know exactly what to do next.

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Problem
Follow-Up Appointments Are Not Scheduled on Time

Manual scheduling delays and poor communication between hospital and outpatient teams cause missed appointments, leading to complications or readmissions.

Solution
Automated Follow-Up Scheduling & Tracking

Using the integrated EHR and coordination engine, blueBriX automatically schedules required post-acute visits, sends reminders, and tracks completion—closing the loop without staff chasing.

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Problem
Care Coordination Across Providers Is Fragmented

Primary care, specialists, home health teams, and rehab centers often operate on disconnected systems, creating gaps in information flow during transitions.

Solution
Unified Care Timeline With Multi-Provider Access

blueBriX consolidates the entire transition-of-care events—notes, vitals, medications, assessments—into a single shared timeline accessible to all authorized care partners.

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Problem
No Real-Time Visibility Into Patient Recover

Providers often don’t know if patients are deteriorating at home until it becomes an emergency.

Solution
Remote Monitoring & Event-Based Alerts

blueBriX integrates vitals, symptoms, and patient-reported data into the EHR, triggering alerts for worsening conditions and automatically assigning tasks for timely interventions.

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The impact

Smooth, well-coordinated post-acute transitions support compliance with CMS’s Hospital Readmissions Reduction Program (HRRP), which penalizes hospitals for avoidable 30-day readmissions. blueBriX equips organizations with the automation, visibility, and timely follow-up capabilities needed to succeed under these evolving policy expectations.

Reduced Avoidable Readmissions

Proactive follow-ups and monitoring help prevent complications, lowering HRRP-related penalty risk.

Faster Transition Completion

Automated scheduling and task routing ensure coordinated handoffs, aligning with CMS expectations.

Stronger Provider Coordination

Unified communication across providers aligns with HRRP’s focus on coordinated, cross-setting care.

Better Patient Confidence & Recovery

Clear instructions and ongoing support improve patient adherence and recovery, tied to value-based programs.

Conclusion

Post-acute care transitions are where patients are most vulnerable and where hospitals face the greatest HRRP risk. With its integrated EHR purpose-built for your care settings and care coordination orchestration platform, blueBriX brings structure, speed, and visibility to every step of the transition, ensuring safer recoveries, stronger communication, and measurable improvements in value-based performance