Days 0 to 2
Discharge detection and interactive contact inside the required two business day window. Members are prioritized by diagnosis, medication count and prior utilization rather than worked in the order they arrive.
Risk-Bearing Organizations
A Continuous Care Model for Patients Who Carry the Most Risk.
From the moment a patient enters a high-risk transition through ongoing care management and medication optimization, Praventa provides the clinical execution layer that keeps care moving forward.
The 30-Day Cliff
Why do transition programs stop before the risk does?
Because most of them are built to a billing window rather than to a contract. The service period is 30 days. The exposure is not.
Every risk-bearing organization knows the pattern. A member leaves the hospital with a changed medication list, a follow-up appointment they may not keep, and prescriptions they may never fill. A program works hard for thirty days and then closes the episode.
Risk does not close with it. Adherence fades over the following months. Duplicate therapies and discharge dosing errors surface weeks later. The members who drove last quarter's inpatient spend appear again in next quarter's.
Transitional care management is a strong clinical framework, and as a standalone service it has a structural limit that matters more to you than to a fee-for-service practice: for an ACO, every TCM claim is Part B spend counted against your benchmark. It pays for itself only if it prevents something costlier. A transition program that does not change downstream utilization makes your numbers worse, not better.
TCM is where we enter. Care management is how we stay engaged. CMM is how we go deeper.
01
Enter
Transitional care management. The discharge identifies a member whose clinical picture has just changed, and gives us a reason to reach them now.
02
Stay
Ongoing care management. Members with continuing clinical, adherence or coordination needs carry forward rather than closing at day 30.
03
Go deeper
Comprehensive medication management. Where regimen complexity or medication risk warrants it, a pharmacist manages the therapy itself.
04
Adapt
Additional services as needed. Chronic care management, remote monitoring, behavioral health integration and wellness workflows, by clinical need.
05
Measure
Outcomes. What was found, what was done, who was told, and what happened to utilization afterward.
Praventa is not a set of disconnected billing programs. It is one longitudinal clinical relationship whose intensity follows the member. A lower-risk member may need the transition and nothing more. A member with significant medication complexity moves into pharmacist management. A high-risk member carries through every level. The point is not to enroll everyone in everything; it is to keep the right members engaged at the right level of care.
The Sequence
What actually happens in the first thirty days, and after them?
The transition is worked to the clinical requirement, not to a checkbox, and the relationship it creates is what carries into month two and beyond.
Days 2 to 14
A clinical pharmacist compares the discharge list, the pre-admission list and pharmacy fill data, resolves discrepancies, flags interactions and duplicate therapy, and routes recommendations to the treating physician before or at the face-to-face visit.
Days 7 to 30
Fills are confirmed, cost and access barriers are addressed, new therapy is taught back, and warning signs are escalated to the care team before they become an emergency department visit.
Day 31 onward
Members who qualify continue into ongoing care and medication management: monthly pharmacist contact, adherence monitoring, dose optimization, and remote monitoring where it applies. The relationship built during the transition is the thing that carries.
Reconciliation Is Not Management
Why medication work cannot be a single event
A medication list reconciled today can be inaccurate tomorrow. Most transitions-of-care models treat reconciliation as the finish line, and it is closer to the starting one.
The prescription may never be filled. The medication may be unaffordable. A side effect may stop the member taking it. A new therapy may interact with something already on the list. The member may simply have misunderstood the regimen. And as the clinical picture changes, a therapy that was right at discharge may stop being right at all.
Reconciliation tells you what a member is supposed to be taking. Comprehensive medication management asks whether the therapy is still working for them, and keeps asking. That is why CMM is the natural clinical follow-on to the transition for the members who need it, rather than a separate product sold alongside it.
Execution, Not Just Analytics
What does your population health platform not already tell you?
Your systems can identify who is high risk, who was admitted, who was readmitted and what was prescribed. What they cannot show is whether anyone reached the member, what was found, and what was done about it.
Praventa records the intervention as it happens: who was identified and engaged, which clinical or medication problems were discovered, what was done about them, who on the care team was notified, and what followed. That is a record of clinical execution rather than of utilization, and it is the half of the picture claims cannot supply.
It does not sit in a vendor portal. Intervention data moves by API into your population health platform, scoped to your system, so discharge detection, contact attempts, completed reconciliations and escalations land next to your claims rather than months behind them. Analytics tells you where the risk is. Execution is what changes it.
Who This Is Built For
Which organizations does this model fit?
Organizations accountable for what a population costs, where a transition is not a billing event but the start of an exposure.
ACOs
Use transitions to identify and intervene with high-risk attributed beneficiaries, with TCM spend modeled against expected avoided utilization before you commit.
Risk-bearing medical groups
Extend an existing care management team without building every clinical function internally, particularly pharmacist capacity.
Management services organizations
Stand up one care management infrastructure that can serve several physician organizations and populations rather than one per client.
Medicare Advantage organizations
Support longitudinal engagement, medication adherence and care coordination within the applicable payer and provider arrangement.
Health systems entering risk
Build post-discharge clinical execution that reaches past the hospital walls and into the attributed population.
Common Questions
Related questions
Does this replace our care management team?
No. It extends one. Praventa adds pharmacist-level medication expertise and the capacity to work every eligible transition on time, in coordination with your physicians, and escalates to your team rather than around it. Clinical leadership, care decisions, the existing member relationships and population strategy stay with you.
Does TCM billing count against ACO shared savings?
Yes. The Medicare Shared Savings Program measures performance on total Part A and Part B expenditures for assigned beneficiaries, and transitional care management is a Part B service, so the claims are spend and count against the benchmark. Revenue and expenditure also land in different places: the practice collects the fee while the ACO carries the expenditure. That is precisely why the model has to change downstream utilization rather than simply generate episodes.
Why not just run transitional care management on its own?
Because the service period ends at thirty days and the exposure does not. Medication-related problems and non-adherence frequently surface after the episode closes, and a completed episode is an activity count rather than an outcome. The transition is worth running because of the relationship it creates, not only the claim it supports.
How do you decide which members continue past day 30?
By clinical criteria applied to your risk stratification rather than by enrolling everyone. Medication count, high-risk drug classes, adherence history, recent transitions and prior utilization drive the decision. A lower-risk member may need the transition and nothing further.
How does this affect quality performance?
Post-discharge work is where several plan and group level measures are actually produced. Timely engagement after an inpatient discharge and medication reconciliation after discharge are both measured, and Part D medication adherence for diabetes medications, hypertension therapy and statins are each weighted heavily. Measure sets and weights are set by star year and program, so confirm which apply to your contract for the year in question rather than assuming.
How does the data reach our systems?
By API integration into your population health platform, scoped to that platform. Discharge detection, contact attempts, completed reconciliations and clinical escalations arrive at intervention level and in near real time, rather than as a monthly report that describes work you can no longer act on.
Let us model your population
Tell us your attributed lives, annual discharges, readmission rate and emergency department utilization, and we will model how a transition-led, longitudinal care management program would sit inside your population and your risk arrangement. No generic assumptions and no predetermined savings percentage.