Close the loop between every provider, plan, and patient.
AXIFI identifies patients at risk of falling through the cracks, automates transition outreach, and surfaces care gaps to the right team member — before the patient is readmitted.
Built on the Synaptis trust layerHIPAASOC 2 Type IIFDA 21 CFR Part 11Trust Center
Care transitions are where outcomes fall apart.
One in five Medicare patients is readmitted within 30 days of discharge. The majority of those readmissions are preventable — the result of failed handoffs, missed follow-up appointments, medication confusion, and patients who do not know what to do next. The system has the information. It just does not act on it fast enough.
- 30-day readmission rate: 18.5% Medicare, 12.3% commercial (CMS, 2023)
- 42% of patients discharged from hospital do not follow up with a primary care provider within 14 days
- Medication discrepancies occur in 60% of care transitions (AHRQ)
- ACOs lose an average of $2,400 per preventable readmission in penalty and cost exposure
Automated transition management from admission to recovery.
Admission and discharge monitoring
AXIFI monitors ADT feeds in real time. When a patient in your attributed population is admitted to any facility, a care coordination workflow is automatically opened.
Risk-stratified transition planning
At discharge, AXIFI assesses readmission risk using a validated model combining diagnosis, social determinants, prior utilization, and medication complexity. High-risk patients get intensive follow-up protocols.
Automated post-discharge outreach
AXIFI contacts the patient within 24–48 hours of discharge to confirm medication understanding, schedule follow-up, and identify barriers. Outreach escalates to a human care manager when clinical complexity requires it.
Closed-loop reporting
Every care coordination event — outreach attempt, appointment scheduled, care gap addressed — is documented in the chart and reported to the accountable care team. No manual tracking spreadsheets.
Fewer readmissions. More closed care loops.
Reduction in 30-day readmission rate
across enrolled ACO population
Post-discharge follow-up completion
within 14 days of discharge
ROI for ACO care management programs
vs. manual coordinator model
30-day readmission rate (%, monthly average)
What is inside Care Coordination.
ADT monitoring
Real-time admit/discharge/transfer feed from all facilities in your attribution network. Workflow opens automatically on every relevant event.
Transition risk model
Validated 30-day readmission and ED revisit models. Scores updated at every chart event during the admission. High-risk flags route to senior care managers.
Automated outreach
Post-discharge call scripting, SMS follow-up, and medication reconciliation prompts. Multilingual. Escalates to human coordinator on abnormal responses.
Care plan management
Structured care plans generated from the discharge summary. Tasks assigned to PCP, specialist, patient, and care manager with automated completion tracking.
Connects your care continuum.
- ADT / hospital
- Epic ADT
- HL7 v2 ADT feeds
- Cerner ADT
- CommonWell Health Alliance
- Carequality
- Population health
- Arcadia
- Innovaccer
- Privia Health
- Evolent Health
- PCMH registry
- Payer / health plan
- CMS ACO REACH feeds
- MSSP data
- Commercial care gap files
- FHIR bulk export
- Community resources
- 2-1-1 SDOH referral APIs
- Unite Us
- FindHelp.org
- Social needs screening (PRAPARE, AHC)
Common questions.
Ready to deploy Care Coordination in your environment?
See how Synaptis fits into your stack — no generic demos, just your workflow.