Designed for compatibility with
Epic Cerner Athenahealth eClinicalWorks Meditech Allscripts
No system overhaul required
Works alongside your existing EHR
Designed for phased adoption
Built on existing operational datasets
Pilot engagements available
Discharge Intelligence · Value-Based Care

Reduce avoidable readmissions before the patient leaves the hospital.

Preventra identifies high-risk discharges, explains the drivers, and gives care teams a prioritized action list — inside their existing workflow.

Designed to add intelligence to your existing EHR, care management, and population health workflows — not replace them
Discharge risk score for every patient — surfaced automatically, with explainable drivers.
Prioritized worklist for your care team — showing which patients need a call, medication review, follow-up visit, or home health coordination.
Built on your existing data and workflows — no overhaul, no retraining, no disruption.
Scroll
$26B+
in avoidable readmission costs annually.
The most preventable cost in U.S. healthcare — driven by gaps in discharge visibility.
1 in 5
patients returns within 30 days.
For Accountable Care Organizations, every return is shared savings lost.
~$15K
average cost per readmission event.
A 10% reduction pays for operational intelligence many times over.
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Your highest-risk patients already exist in your data.

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.

Works With Your Existing Systems

Designed to add intelligence to your existing workflows — not replace them.

Built on existing datasets

No new data infrastructure. Works with your existing clinical and operational data from day one.

No workflow disruption

Discharge planners and care coordinators get prioritization support without changing how they work.

Phased adoption

Start with one unit or cohort. Expand as teams build familiarity. Value realized from session one.

Works With Your Existing Infrastructure

Discharge risk intelligence at the point of care
Automatic prioritization worklists for care teams
Transitional care visibility and coordination support
Transitional Care Management workflow and billing support
Compatible with Epic, Cerner, and modern EHR ecosystems
PREVENTRA · DISCHARGE CONSOLE TODAY 43 HIGH RISK 11 MODERATE 17 LOW RISK 15 91 ACT 87 ACT 74 ACT Discharge intelligence designed for the people who use it. Care coordinator · Morning rounds · 08:41 AM
Built for nurses, discharge planners, and care coordinators — not for systems administrators.
90% operational · 10% human · 0% stock photo
Care coordinator · Discharge planner · Transitional care nurse
Who It's For

Built for organizations managing value-based care at scale.

Designed for care environments where readmission rates directly impact shared savings, financial performance, and clinical team capacity.

Primary

Accountable Care Organizations

Every avoidable readmission erodes shared savings. Preventra gives Accountable Care Organization care teams discharge visibility to protect financial performance — without adding operational burden.

  • Shared savings impact modeling
  • Population risk stratification at discharge
  • Transitional Care Management workflow support
Primary

Hospitals & Health Systems

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 risk scoring for every patient
  • Automatic prioritization worklist
  • No-show risk for follow-up appointments
Primary

Transitional Care Teams

Discharge planners and transitional care nurses get clinical prioritization support without learning a new system or changing existing workflows.

  • Explainable risk drivers in plain clinical language
  • Recommended next actions at point of care
  • Designed around existing transitional care workflows
Also Designed For

Physician Groups & Clinically Integrated Networks

Discharge operational intelligence layered into existing clinical environments — without requiring a new platform investment or IT overhaul.

  • Value-based care contract performance support
  • Population health operational visibility
Also Designed For

Care Management Leadership

Chief Medical Officers, VP Population Health, and Chief Financial Officers get population-level trends and performance data — without adding complexity to clinical teams.

  • 30-, 60-, 90-day readmission trending
  • Shared savings performance reporting
Also Designed For

Value-Based Care Organizations

Medicare Shared Savings Program participants and value-based care networks — built around the financial and operational realities you face every day.

  • Medicare Shared Savings Program performance support
  • Rapid adoption without IT burden
How It Works

Discharge operational intelligence that predicts, prioritizes, and prevents.

Every patient gets a clear risk score at discharge with key drivers surfaced. Your care team gets a prioritized worklist and recommended coordination actions — without changing how they work.

01 — Predict

Risk Score at Discharge

Every patient receives an explainable risk score before leaving — primary clinical drivers surfaced in plain language. No interpretation required. No additional clicks.

02 — Prioritize

Automatic Prioritization Worklist

The most critical patients appear first — automatically. No manual sorting. Your team sees exactly where to focus the moment they open their workflow.

03 — Prevent

Recommended Coordination Actions

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

Designed around real transitional care challenges.

Built to help care coordination teams identify high-risk patients before discharge — without adding operational burden or requiring new infrastructure.

Avoidable Readmission Reduction

Identify highest-risk patients before discharge. Prioritized worklists ensure clinical attention reaches the right patients before a preventable readmission occurs.

Transitional Care Prioritization

Discharge planners get automatically ranked patient lists — directing nurse bandwidth to patients who need the most support before leaving.

Transitional Care Management Visibility

Transitional Care Management billing opportunities and care gaps surfaced automatically — supporting clinical and revenue cycle workflows simultaneously.

Discharge Follow-Up Coordination

No-show risk flags patients unlikely to attend follow-up appointments — enabling proactive outreach before the care gap becomes a readmission event.

Care Management Efficiency

Care teams spend less time sorting data and more time on direct patient intervention. The manual prioritization burden is eliminated entirely.

Shared Savings Protection

Every avoidable readmission prevented is shared savings protected. Preventra provides the discharge-level visibility Accountable Care Organizations need to meet financial targets.

The discharge operational intelligence layer your transitional care team has been waiting for.

Not a new system. Not another dashboard. Operational intelligence built on your existing data — adding discharge visibility, care team prioritization, and coordination support to workflows your teams already use.

Accountable Care OrganizationsHospitalsPhysician GroupsClinically Integrated NetworksTransitional Care TeamsValue-Based Care Networks
$1M+
Potential annual savings per hospital
10%
Readmission reduction target
<60s
Clinician action time per patient
See It In Action

From risk score to daily care-team action list.

Every patient flagged. Every driver explained. Every care team action prioritized — automatically, inside the workflows your team already uses. Complements your Electronic Health Record — doesn't replace it.

Compatible with existing care management environments Batch & real-time workflow support Designed for phased adoption Healthcare data governance by design
Valley Medical Center · Unit 4 · Discharge Intelligence Console
SR
S. Reyes, RN · Care Coordinator · 08:41 AM · May 8, 2026
3 new high-risk patients added overnight — worklist updated automatically 08:38 AM
Discharging Today
43
+3 overnight
High Risk
11
Needs action
Moderate Risk
17
Monitor closely
Low Risk
15
Standard discharge
Priority Worklist — Discharge Today11 High Risk
Updated 08:41 AM
M. Rodriguez, 71 · Rm 412B
MRN 004821 · Cardiology · Dr. Chen · Admit: May 4
Prior admissions × 3 · CHF · High no-show risk
91
T. Washington, 83 · Rm 508
MRN 007345 · Internal Medicine · Dr. Okafor · Admit: May 3
Polypharmacy · Social isolation · COPD
87
S. Chen, 67 · Rm 301A
MRN 009102 · Endocrinology · Dr. Patel · Admit: May 5
ED visit Apr 18 · Diabetes · Uncontrolled HbA1c
74
A. Patel, 78 · Rm 214
MRN 003670 · Nephrology · Dr. Yuen · Admit: May 6
No PCP follow-up scheduled · Renal insufficiency
68
L. Johnson, 59 · Rm 119
MRN 006511 · Surgery · Dr. Martinez · Admit: May 6
Limited health literacy · Post-surgical · Caregiver gap
53
Top Risk Drivers · Unit 4
Prior Admissions
73%
No-Show Risk
61%
ED Visits (90d)
48%
Polypharmacy
39%
No Follow-up
34%
30-Day Trend · Valley Medical
Readmission rate ↓ 18% · Apr vs Mar
Team Activity · 08:41 AM
S. Reyes, RN4 reviewed
K. Torres, RN2 reviewed
J. Park, Care Coord.Pending login
Under 60 seconds. Primary risk driver visible immediately — no extra clicks.
Sorted automatically. Most critical patients always appear first.
Layered onto existing systems. Works alongside your Electronic Health Record — no overhaul required.
Implementation Reality

Operationally lightweight by design.

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.

01

Connect to existing datasets

Works with your existing admission records, discharge patterns, and clinical history. No new data warehouse or infrastructure build required.

02

Phased rollout — no clinical disruption

Start with one unit or pilot cohort. Expand as teams build familiarity. Organization-wide rollout is not required before value is realized.

03

Minimal IT burden

Clinical staff begin using the discharge intelligence console without a retraining program. Extended IT involvement is not required for deployment.

04

Value visible from day one

From the first discharge prioritization session, care coordinators see a ranked worklist, explainable risk scores, and recommended coordination actions — immediately.

Operationally lightweight

No workflow disruption.

Preventra adds discharge operational intelligence to your existing environment. No new logins replacing existing systems. No retraining programs. No operational overhaul of any kind.

Pilot Engagements Available

Evaluate before you commit.

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 Conversation →

Healthcare data governance by design.

Built for modern healthcare operational environments — data governance and operational security considerations integrated into the architecture, not added afterward.

Depth Where It Matters

From individual patient risk to population-level insight.

One discharge operational intelligence layer. Two audiences. Discharge planners get what they need at the bedside. Leadership gets what they need in the boardroom.

For Care Coordinators & Discharge Planners

Explainable Patient-Level Risk

Key risk drivers shown in plain clinical language — no training required, no new system to navigate. Designed to support existing transitional care workflows.

  • Prior admission history and frequency
  • Emergency Department visit patterns within 90 days
  • No-show and appointment adherence risk
  • Social determinants and care support gaps
  • Recommended coordination actions at point of care
For Operational Leadership

Population Insights Without Added Complexity

Population-level discharge visibility and performance trends — enabling care coordination impact measurement, team benchmarking, and shared savings reporting within existing processes.

  • 30-, 60-, and 90-day readmission rate tracking
  • Top risk driver trends across patient population
  • Care team performance benchmarking
  • Shared savings impact modeling
  • Exportable reports for quality committee review
Why Preventra

Operational augmentation for value-based care. Not another analytics layer.

Built for the realities of clinical discharge workflows — designed to support existing teams without adding burden to the nurses, discharge planners, and care coordinators on the ground.

Clinicians act in seconds, not minutes

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 operational reality.

No-show risk — standard, not optional

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.

Batch and real-time — both supported

Morning rounds worklist or real-time discharge support — Preventra supports both operational models, adapting to how your organization already works.

Operational augmentation — not replacement

You already have forecasting and Electronic Health Record infrastructure. Preventra integrates as a discharge operational intelligence layer — no rip-and-replace, no IT overhaul. Built for Accountable Care Organizations, hospitals, physician groups, clinically integrated networks, and value-based care organizations that cannot afford implementation friction.

Start Today

Explore how Preventra fits into existing care coordination workflows.

Limited pilot engagements available — using existing datasets, no long-term commitment.
No operational disruption — designed for phased adoption from day one.
$1M+ potential annual savings — from a 10% reduction in avoidable readmissions.
Protect shared savings — discharge visibility before patients leave, not after they return.
$1M+
potential annual savings for a typical hospital from a 10% reduction in avoidable readmissions — achieved through better discharge visibility and prioritized care coordination, layered onto existing systems.
Based on average readmission costs of approximately $15,000 per event and typical hospital readmission volume. Actual results vary by organization size and baseline readmission rate.

Frequently Asked Questions

» General

Preventra 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 — visit history, medications, diagnoses, 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 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.

» For Hospitals & Health Systems

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 — so 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.

For Clinical & Care Teams

At discharge planning, a risk score appears alongside the patient record. No extra data entry is required — 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.

For ACOs & Payers

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.