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For health systems and hospitals
Follow every patient home for the 30 days that matter most.
HSRMed supports care transitions, readmission programs and remote monitoring at scale. Care managers see who is slipping after discharge and step in early, with the hospital's own protocols.
- Transitions board for every discharged patient, ranked by change
- Follow-up gaps: visits not scheduled, medication reviews pending
- Program reporting by unit, service line and payer
- Enterprise ready: HL7 FHIR, single sign-on, role-based access
The challenge
Discharge is not the end of the episode
Many readmissions start with small changes at home in the first days after discharge.
The first two weeks
Patients go home with new medications and instructions, and the first warning signs often appear before the first follow-up visit.
Penalties and lost capacity
Avoidable readmissions cost money, beds and staff time, and can affect quality scores and contracts.
Care managers stretched thin
Phone lists and spreadsheets do not tell a team who to call first.
Sample screen
Care transitions board
Every patient discharged in the last 30 days, with their trend, follow-up status and next step.
| Patient | Since discharge | HSI | Trend | Readmission risk | Follow-up visit | Medication review | Next step |
|---|---|---|---|---|---|---|---|
| Patricia MooreHeart failure | Day 3of 30 | 58 | High | Not scheduled | Pending | Care manager: call today | |
| Kevin TurnerCOPD exacerbation | Day 5of 30 | 64 | Medium | Day 7 | Done | Telehealth on day 7 | |
| Elena RossiPneumonia | Day 9of 30 | 71 | Low | Done | Done | Improving; continue | |
| Marcus LeeHeart failure | Day 12of 30 | 62 | High | Day 14 | Done | Nurse call: weight up 4 lb | |
| Hannah SchmidtHip replacement | Day 2of 30 | 73 | Low | Day 10 | Done | On track | |
| Jorge AlvarezSepsis, recovering | Day 6of 30 | 60 | Medium | Not scheduled | Pending | Schedule follow-up visit | |
| Naomi ClarkDiabetes, DKA | Day 18of 30 | 76 | Low | Done | Done | Graduating day 30 | |
| Samuel OwusuAMI with stent | Day 21of 30 | 67 | Medium | Done | Done | Cardiology message |
30-day program flow
Last 90 days, all units
Alerts handled within 24 hours
Share of alerts with a documented contact, by week
What HSRMed delivers
One platform for transitions and remote monitoring
Transitions board
All discharged patients in one view, ranked by change from their own baseline, with follow-up status.
Escalation rules
Alerts routed by unit and role, with escalation if no one responds within the time you set.
EHR and ADT integration
Enrollment can start from discharge events. Notes and tasks are written back to the chart, based on HL7 FHIR.
Program reporting
Enrollment, engagement, alert response time and readmissions, by unit, service line and payer.
Security and governance
Role-based access, audit logs, single sign-on and encryption in transit and at rest.
Remote monitoring at scale
Run heart failure, COPD, diabetes and post-surgical programs from one platform, with consistent documentation.
How it works
From discharge to day 30
Enroll at discharge
Eligible patients are flagged on discharge and enrolled with consent, in their language.
Monitor at home
Patients use connected devices and the HSRMed app. Data arrives daily.
Act on change
Care managers work a ranked list and document each contact. Escalations follow your protocols.
Report results
Leaders see enrollment, engagement, response times and readmissions for each program.
What you can measure
Program metrics for leadership
Questions
Questions from health systems
Can enrollment start from our discharge process?
Yes. HSRMed is designed to receive discharge events and patient information through standards-based integration (HL7 FHIR), so care managers do not re-enter data.
Does HSRMed replace our care management platform?
No. HSRMed adds continuous home data and prioritization. Tasks and notes can flow into the systems your teams already use.
Which programs can we run?
Care transitions, heart failure, COPD, diabetes, hypertension, post-surgical recovery and other remote monitoring programs.
How is data protected?
Encryption in transit and at rest, role-based access, audit logs and single sign-on. We review security requirements with each health system.
Plan a transitions pilot
Start with one unit or one condition, and measure the results with your own data.
Who we serve