Post-Discharge Intelligence for SNFs

Close the gap
after discharge.

TCIQ equips skilled nursing facilities with AI-powered post-discharge outreach, CoreQ satisfaction surveys, discharge education workflows, and VBP analytics — built on PointClickCare FHIR.

Request Early Access → See the Platform
TCIQ · Discharge Queue PCC Live
Pending Education — Today
Margaret T. Sullivan
Age 83 · CHF · Lives alone
High · 87
Dorothy A. Williams
Age 81 · Post-stroke · HH confirmed
High · 79
Harold J. Kowalski
Age 87 · Hip fracture · Daughter local
Med · 54
VBP Performance — This Month
17.2%
Readmission Rate
91%
Education Complete
88%
AI Follow-up Rate
$31.6K
VBP Exposure
71%
of SNFs penalized under Value-Based Purchasing in 2024
67%
of SNF readmissions are considered preventable
30
day post-discharge window with no technology layer today
$325
per building per month for anonymous postal mail satisfaction surveys — with no attribution
The Problem

The 30-day window
has no technology layer.

SNFs invest heavily in in-facility care. The moment a resident goes home, the connection breaks — and readmissions follow.

25%
Readmitted within 30 days
One in four SNF patients returns to the hospital within a month of discharge. Most are preventable with timely outreach and early concern detection.
2%
VBP penalty on Medicare revenue
CMS withholds up to 2% of Medicare reimbursement from high-readmission facilities. For a mid-sized building that's $18,000–$40,000 per year at risk.
0
Attributed satisfaction data today
Postal mail CoreQ surveys arrive weeks late and anonymous. Leadership sees averages — not which residents were dissatisfied, which staff need coaching, or which buildings are trending down.
The Platform

Four surfaces.
One connected workflow.

TCIQ connects the discharge coordinator, the AI agent in the field, CoreQ satisfaction collection, and leadership in the dashboard — from a single PointClickCare FHIR integration.

◈
Discharge Workflow
A 6-step education workflow auto-generated from the resident's PCC FHIR record. Diagnoses, medications, warning signs, and family contacts pre-populated. TCPA consent and outreach preference captured before the resident leaves.
⟳
AI Post-Discharge Outreach Agent
Automated clinical check-ins via SMS and voice at 48 hours and 7 days post-discharge — using the facility's own caller ID. Constrained response options ensure clinical data reliability. Concern flags route to the designated escalation contact in real time.
★
CoreQ Satisfaction Survey
NQF-endorsed CoreQ Short Stay Discharge questions administered via AI agent at 7 days post-discharge. Fully attributed to named residents. Results uploaded to AHCA LTC Trend Tracker automatically. Replaces postal mail survey vendors.
NQF Endorsed · LTC Trend Tracker
◎
Leadership Analytics Dashboard
VBP exposure, readmission trends, education compliance, AI follow-up rates, and CoreQ satisfaction scores — at the building level and across the regional network. Role-separated views for DONs and regional operators with HIPAA audit logging.
AI Agent — 48-Hour Check-in · Frank D. Moretti
①
Outreach initiated via SMS
TCIQ AI → Eleanor Moretti (Wife) · (563) 555-0388 · Facility caller ID
②
Daily weigh-in not occurring
"He says the scale is hard to get to." Critical for CHF monitoring.
⚠ Concern
③
Ankle swelling increased
"His ankles look puffier since yesterday." Edema progression flagged.
⚠ Concern
④
Shortness of breath on exertion
"Got winded going to the bathroom." Escalation triggered.
🚨 Escalate
✓
Escalation contact notified
3 concerns · DON Maria Torres notified · 10:12 AM
CoreQ Satisfaction Surveys

Replace your postal mail
vendor — with attribution.

TCIQ collects NQF-endorsed CoreQ Short Stay Discharge questions via AI agent at 7 days post-discharge. Fully attributed. Real-time. Uploaded to AHCA LTC Trend Tracker automatically.

⚡
Results in days, not weeks
Postal mail surveys take 3–4 weeks to arrive and process. TCIQ collects CoreQ responses at 7 days post-discharge and surfaces results in the leadership dashboard immediately — while there's still time to act on them.
◈
Full attribution — no anonymity
Every CoreQ response is attributed to a named resident, discharge date, discharge coordinator, and building. Leadership can identify patterns, coach staff, and address concerns — not just read anonymous averages.
↑
Higher response rates
AI-powered phone and SMS outreach using the facility's own caller ID significantly outperforms postal mail return rates. Families primed during the discharge education session are more likely to respond.
★
LTC Trend Tracker upload included
TCIQ uploads CoreQ results to AHCA's LTC Trend Tracker on behalf of participating facilities — the same destination your current vendor uses, with better data and faster turnaround.
What TCIQ replaces
Postal mail survey vendorAnonymous→ Attributed
Results timeline3–4 weeks→ 7 days
Manual call processStaff labor→ Automated
LTC Trend TrackerSeparate vendor→ Included
Leadership reportingMonthly PDF→ Real-time
CoreQ Short Stay Discharge Survey NQF Endorsed
Question 1 of 4
How would you rate the care and services you received at this facility?
PoorExcellent
Question 2 of 4
How would you rate how well the staff worked together to provide your care?
PoorExcellent
Question 3 of 4
In recommending this facility to friends and family, how would you rate it overall?
PoorExcellent
Question 4 of 4
How well did staff prepare you to care for yourself after leaving the facility?
PoorExcellent
Building CoreQ Score
Utica Ridge · Apr 2026
82%
Attribution example
Margaret Sullivan · Discharged Apr 18 · Coordinator: Maria Delgado · Overall: 4/5 · Discharge prep: 3/5 — follow up with discharge team on education clarity
How It Works

From discharge to
30-day follow-up.

A single workflow that requires no new staff hires and adds less than 15 minutes to the existing discharge process.

Step 01
Discharge Education
An ADT discharge event in PointClickCare triggers the TCIQ discharge workflow. Conditions, medications, warning signs, and family contacts are auto-populated from the resident's PCC FHIR record. TCPA consent and family contact preference — SMS, voice, or both — are captured before the resident leaves the building.
Step 02
AI Outreach + CoreQ
TCIQ contacts the family at 48 hours with clinical check-in questions. At 7 days, the clinical check-in is followed by the four CoreQ Short Stay Discharge questions — in the same AI agent interaction, using the facility's own caller ID. Concern flags route to the designated escalation contact in real time. No new staff required.
Step 03
Review, Documentation & Reporting
Clinical concerns surface in the TCIQ dashboard for review. Staff push notes to PointClickCare under their own credentials. CoreQ scores are attributed to named residents and uploaded to AHCA LTC Trend Tracker automatically. Leadership sees readmission trends, VBP exposure, and satisfaction scores in one real-time dashboard.
Technical Foundation

Built on PointClickCare FHIR.

TCIQ integrates with PointClickCare via the USCDI Connector FHIR API. ADT discharge events trigger the workflow automatically — no manual data entry, no duplicate charting.

TCIQ is built as a Provider-facing and Bulk SMART on FHIR application targeting the USCDI v1 data set. Infrastructure runs on HIPAA-eligible Microsoft Azure with database-per-tenant isolation, customer-managed encryption keys, and 6-year audit log retention. CoreQ data is collected via AI agent and uploaded to AHCA LTC Trend Tracker.

PointClickCare FHIR USCDI Connector SMART on FHIR Microsoft Azure Azure Health Data Services HIPAA Compliant CoreQ — NQF Endorsed AHCA LTC Trend Tracker Entra External ID Twilio HITRUST (planned) SOC 2 Type II (planned)
FHIR Resources — USCDI v1PCC Connector
PatientDemographics, identifiers
RelatedPersonFamily contacts, relationships
ConditionActive diagnoses, ICD-10 codes
MedicationRequestDischarge medication list
CarePlanPost-discharge care instructions
CareTeamResponsible clinical contacts
CoverageMedicare / payer information
ADT NotificationsDischarge event triggers
Early Access

Built for SNF operators ready for what's next.

TCIQ is in active development. We're working with a small group of regional operators to validate the platform before broader release. If you're ready to close the post-discharge gap, reach out.

Request Early Access →
Questions? matt.zumwalt@gotciq.com  ·  GoTCIQ.com  ·  Davenport, Iowa