Discharge Intelligence · Value-Based Care
The readmission problem doesn't begin when a patient returns. It often begins before they leave. Preventra identifies high-risk discharges, explains the drivers in plain language, and gives care teams a prioritized action list inside their existing workflow. Currently purpose-built for diabetic patients, layered onto your EHR, care management, and population health workflows.
Designed for compatibility with
The Problem
in avoidable readmission costs annually. The most preventable cost in U.S. healthcare.
patients returns within 30 days. For ACOs, every return is shared savings lost.
average cost per readmission event. A 10% reduction pays for operational intelligence many times over.
Most care teams have forecasting tools, but lack prioritized discharge visibility at the moment it matters most. Predictions are generated. Sorting and acting are left to the team. Preventra closes that gap, adding discharge operational intelligence alongside your existing systems to turn data into immediate, actionable care coordination.
Preventra · Discharge Console
Every patient flagged. Every driver explained. Every care team action prioritized, automatically, inside the workflows your team already uses. Complements your EHR, doesn't replace it.
Valley Medical Center · Unit 4 · Discharge Intelligence Console
S. Reyes, RN · Care Coordinator · 08:41 AM
Discharging Today
+3 overnight
High Risk
Needs action
Moderate Risk
Monitor closely
Low Risk
Standard discharge
Priority Worklist, Discharge Today · 11 High Risk
M. Rodriguez, 71 · Rm 412B
Cardiology · Dr. Chen · Prior admissions × 3 · CHF · High no-show risk
T. Washington, 83 · Rm 508
Internal Medicine · Dr. Okafor · Polypharmacy · Social isolation · COPD
S. Chen, 67 · Rm 301A
Endocrinology · Dr. Patel · ED visit Apr 18 · Diabetes · Uncontrolled HbA1c
A. Patel, 78 · Rm 214
Nephrology · Dr. Yuen · No PCP follow-up scheduled · Renal insufficiency
Top Risk Drivers · Unit 4
30-Day Trend · Valley Medical
Readmission rate ↓ 18%
Apr vs Mar
Under 60 seconds per patient. Sorted automatically, most critical patients always appear first.
Who It's For
Every avoidable readmission erodes shared savings. Preventra gives care teams discharge visibility to protect financial performance, without adding operational burden.
High-risk and low-risk patients leave looking the same. Preventra gives discharge planners an automatic prioritization worklist, so critical patients are addressed before they walk out.
Discharge planners and transitional care nurses get clinical prioritization support without learning a new system or changing existing workflows.
Discharge operational intelligence layered into existing clinical environments, without requiring a new platform investment or IT overhaul.
CMOs, VP Population Health, and CFOs get population-level trends and performance data, without adding complexity to clinical teams.
MSSP participants and VBC networks, built around the financial and operational realities you face every day.
How It Works
Every patient receives an explainable risk score before leaving, primary clinical drivers surfaced in plain language. No interpretation required. No additional clicks.
The most critical patients appear first, automatically. No manual sorting. Your team sees exactly where to focus the moment they open their workflow.
Recommended next steps surface alongside each risk score, giving discharge planners a concrete starting point for follow-up scheduling and transitional care coordination.
Operational Outcomes
Identify highest-risk patients before discharge. Prioritized worklists ensure clinical attention reaches the right patients before a preventable readmission occurs.
Discharge planners get automatically ranked patient lists, directing nurse bandwidth to patients who need the most support before leaving.
Transitional Care Management billing opportunities and care gaps surfaced automatically, supporting clinical and revenue cycle workflows simultaneously.
No-show risk flags patients unlikely to attend follow-up appointments, enabling proactive outreach before the care gap becomes a readmission event.
Care teams spend less time sorting data and more time on direct patient intervention. The manual prioritization burden is eliminated entirely.
Every avoidable readmission prevented is shared savings protected. Discharge-level visibility ACOs need to meet financial targets.
Potential annual savings per hospital
Readmission reduction target
Clinician action time per patient
Implementation Reality
How hard? How long? Will IT get overwhelmed? Preventra was built to answer those questions before they're asked, with a phased deployment approach designed around your existing environment.
Works with your existing admission records, discharge patterns, and clinical history. No new data warehouse or infrastructure build required.
Start with one unit or pilot cohort. Expand as teams build familiarity. Organization-wide rollout is not required before value is realized.
Clinical staff begin using the discharge intelligence console without a retraining program. Extended IT involvement is not required for deployment.
From the first discharge prioritization session, care coordinators see a ranked worklist, explainable risk scores, and recommended coordination actions, immediately.
Limited pilot engagements available for healthcare organizations to evaluate discharge risk visibility, care team prioritization, and transitional care workflows, using existing datasets and current infrastructure. No long-term commitment required.
Request a Pilot ConversationWhy Preventra
Discharge planners can review, interpret, and act on a patient's risk profile in under a minute. Speed matters at discharge, Preventra is built around that reality.
No-show risk is a core driver, a factor most discharge tools ignore. If a high-risk patient is likely to miss their follow-up, your team knows before discharge.
Morning rounds worklist or real-time discharge support, Preventra supports both operational models, adapting to how your organization already works.
You already have forecasting and EHR infrastructure. Preventra integrates as a discharge operational intelligence layer, no rip-and-replace, no IT overhaul.
Ways to Engage
We analyze a sample of your existing data and return a population level risk profile and an estimate of your current exposure. No commitment required.
Request a Data AssessmentDeploy Preventra across a defined unit or patient cohort. Measure outcome change, care team workflow impact, and early financial signals against your baseline.
Discuss a PilotExpand across your full population with live worklists, automated risk prioritization, and ongoing outcomes reporting.
Plan a DeploymentThe data assessment produces actionable insight regardless of what comes next.
Frequently Asked Questions
It is a discharge intelligence layer that gives hospitals and care teams early visibility into which diabetic patients are at elevated risk of returning within 30 days of discharge. It sits alongside your existing EHR and surfaces a clear, explained risk signal at the point where it matters most: discharge planning.
At or near discharge, Preventra reviews information already in the patient's chart, such as visit history, medications, diagnoses, and length of stay, and produces a risk score. Every score comes with a plain-language explanation of what's driving it, so care teams know not just who to prioritize, but why.
No. Preventra is a decision-support layer, not a decision-maker. It surfaces a prioritized, explained signal so your team can direct limited follow-up resources where they're likely to matter most. The clinical call always stays with your team.
Preventra is currently purpose-built for diabetic patients rather than the general inpatient population, and every prediction includes a patient-level explanation: not just a score, but the specific factors behind it for that patient.
No. Preventra is designed to integrate with the systems you already use rather than replace them. It's an added layer of discharge visibility, not a new system your team has to learn from scratch.
Excess 30-day readmissions can carry real financial consequences under CMS's Hospital Readmissions Reduction Program. Preventra gives your team earlier, more specific visibility into which patients are likely to return, so care coordination resources can be directed before discharge rather than after a repeat visit.
Preventra is delivered as a SaaS platform designed to work with standard EHR data structures. Our team works alongside your IT and implementation staff to scope integration and timeline for your specific environment.
Most existing programs rely on manual chart review or general-purpose risk tools. Preventra adds a layer trained specifically on the patient population you're trying to manage, with transparent, patient-level reasoning behind every flagged case. Your existing program gets a sharper, faster signal, not a replacement.
We help you track the readmission rate among flagged, intervened-on patients against a comparable baseline, so impact is measurable rather than assumed.
At discharge planning, a risk score appears alongside the patient record. No extra data entry is required, because Preventra pulls from information already in the chart. Reviewing a flag takes seconds.
You shouldn't trust it instead of your judgment. It's built to support it. Preventra is most useful for patients who look stable at discharge but carry risk factors that are easy to miss in a busy workflow. It's a second set of eyes across dozens of risk factors at once, not a replacement for clinical experience.
Preventra flags, it doesn't prescribe. Your team's care coordination protocol governs the response: a post-discharge follow-up call, a scheduled primary care visit, medication reconciliation, or a referral to a transitional care program.
Yes, always. The score is a data-driven input, not a directive. If your clinical judgment differs from the flag, your judgment takes precedence.
No. It's built to reduce the time spent manually reviewing charts for risk, not add to it. Reviewing a flag and its explanation takes moments.
Every 30-day readmission is a second claim. A hospital using a systematic, explainable readmission tool represents a meaningfully different risk profile in your network: fewer repeat claims, and stronger performance on readmission-related quality metrics.
Preventra's discharge-level risk signal is a natural input into population health and care management workflows, helping direct chronic care and medication adherence outreach to the patients who need it most.
Preventra works from structured clinical data already present in standard EHR exports: diagnoses, medications, visit history, and administrative fields like payer type and length of stay. No free-text notes or imaging are required.
The risk score and its explanation give care management teams a clear starting point: not just which patients need outreach, but what's actually driving their risk, enabling more targeted intervention.
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$1M+ potential annual savings for a typical hospital from a 10% reduction in avoidable readmissions. Based on average readmission costs of approximately $15,000 per event. Actual results vary by organization.