Post-Discharge Intelligence for SNFs

Close the gap
after discharge.

TCIQ calls your discharged residents at 48 hours and 7 days to check the warning signs for their diagnoses, flags concerns to your team, and runs the CoreQ survey by phone at day 14 — built on your facility's EHR data via FHIR.

Request Early Access → See the Platform
▶
Hear TCIQ in action
48-hour check-in call · 2:14 · full transcript
Listen →
TCIQ · Discharge Workflow EHR sync · 7m ago
Going home today
Margaret T. Sullivan
Age 83 · Heart failure · Home
Consent pending
Dorothy A. Williams
Age 81 · Stroke · Home
Education pending
Harold J. Kowalski
Age 87 · Hip fracture · Home
Ready ✓
Post-Discharge Follow-Up — This Month
42
Check-in Calls
91%
Consent Captured
82%
CoreQ Satisfied
3
Concerns Flagged
Illustrative — sample data
71.7%
of SNFs were penalized under Medicare's SNF Value-Based Purchasing Program (FY2024)1
33.1%
of penalized SNFs received the maximum 1.98% payment reduction (FY2024)1
1 in 4
SNF patients are readmitted to the hospital within 30 days of discharge2
1 Wheeler et al., J Am Geriatr Soc, 2025. doi:10.1111/jgs.70025 2 Mor et al., Health Affairs, 2010;29(1):57–64.
The Problem

The weeks after discharge
are a blind spot.

SNFs invest heavily in in-facility care. Once a resident goes home, most buildings don't hear how they're doing until something goes wrong.

25%
Readmitted within 30 days
One in four SNF patients returns to the hospital within a month of discharge. (Mor et al., Health Affairs, 2010)
2%
Of Medicare Part A payments withheld
Under Value-Based Purchasing, CMS withholds 2% of a participating SNF's Medicare fee-for-service Part A payments and returns 60% of the pool based on performance, so most facilities get back less than was withheld. From FY 2027, one of the eight measures is successful discharge to the community: no unplanned hospital readmission and no death in the 31 days after the resident goes home. (CMS SNF VBP FY 2027 Fact Sheet)
0
Attributed satisfaction data today
Mailed CoreQ surveys come back weeks later and anonymous. Leadership sees averages — not which residents were dissatisfied or why.
The Platform

Four surfaces.
One connected workflow.

TCIQ connects the discharge coordinator, the automated check-in calls, CoreQ satisfaction collection, and leadership in the dashboard — on top of a FHIR integration with your facility's EHR.

Discharge Workflow
A step-by-step discharge workflow for the coordinator. Resident details, diagnoses, and family contacts come from the EHR via FHIR; the coordinator reviews the warning signs with the resident and family and captures TCPA consent before the resident leaves.
AI Post-Discharge Outreach Agent
Automated voice check-ins at 48 hours and 7 days post-discharge that walk through the warning signs for the resident's diagnoses. The call doesn't diagnose or give medical advice; anything reported is flagged and emailed to your designated contact when the call ends.
CoreQ Satisfaction Survey
The four CoreQ Short Stay Discharge questions, read word for word in a separate automated call at 14 days post-discharge and scored on the keypad. Each response is tied to the discharge. AHCA, the measure steward, confirmed in writing that automated phone administration is acceptable.
PQM-Endorsed · Verbatim · Keypad-Scored
Leadership Analytics Dashboard
Check-in calls, flagged concerns, consent capture, and CoreQ satisfaction scores — at the building level and across the regional network. Role-separated views for DONs and regional leaders, with every resident-level data view audit-logged.
48-Hour Check-in Call · Frank D. Moretti
①
Voice call connected
Automated check-in → Eleanor Moretti (wife, family contact)
②
Feeling since discharge
"He's been tired, but getting around the house."
Noted
③
Warning sign: new swelling
"His ankles look puffier since yesterday." His instructions say to call the provider — the call relays that.
⚠ Concern
④
Warning sign: trouble breathing
"He got winded going to the bathroom." Asked if it's happening now — "No, it passed."
⚠ Concern
✓
Escalation contact emailed
2 concerns · summary sent to DON Maria Torres when the call ended · 10:12 AM
CoreQ Satisfaction Surveys

CoreQ by phone —
tied to the discharge.

TCIQ administers the PQM-endorsed CoreQ Short Stay Discharge survey in a separate automated call at 14 days post-discharge — the four questions read word for word, answered on the keypad, and tied to the discharge.

Results the day of the call
Mailed surveys take weeks to come back. TCIQ calls at 14 days post-discharge and each response shows up in the leadership dashboard as soon as the call ends — while there's still time to act on it.
Every response tied to a discharge
Each CoreQ response is linked to the resident, discharge date, discharge coordinator, and building. Leadership can see patterns and follow up on concerns — not just read aggregate averages.
Scored on the keypad, not by AI
The pressed digit is the score — no AI interpretation anywhere in scoring — and every question and answer is kept as a verbatim audit trail. AHCA confirmed in writing that automated phone administration is acceptable.
Designed for higher response rates
A phone call at day 14 is designed to outperform mailed-survey return rates. Response rates will be measured on real discharges, not assumed.

Postal-based CoreQ vendors collect satisfaction data through mailed paper surveys — a process measured in weeks, with manual data entry and batch reporting before a facility sees a single result. TCIQ delivers each response to your dashboard when the call ends.

What TCIQ replaces
Postal mail survey vendorUnattributed→ Attributed
Results timelineWeeks→ Same day
Manual call processStaff labor→ Automated
Leadership reportingBatch reports→ Live dashboard
CoreQ Short Stay Discharge Survey Verbatim Items
Question 1 of 4
In recommending this facility to your friends and family, how would you rate it overall?
PoorExcellent
Question 2 of 4
Overall, how would you rate the staff?
PoorExcellent
Question 3 of 4
How would you rate the care you receive?
PoorExcellent
Question 4 of 4
How would you rate how well your discharge needs were met?
PoorExcellent
Building CoreQ Score
Riverfront Care Center · Apr 2026
82%
Attribution example
Margaret Sullivan · Discharged Apr 18 · Coordinator: Maria Delgado · Overall: 4/5 · Discharge needs met: 3/5
How It Works

From discharge to
day-14 follow-up.

A single workflow built to fit your existing discharge process — the calls run themselves, so no new staff are needed to make them.

Day 0
Discharge
Warning signs reviewed and consent captured before the resident leaves.
48 Hours
Check-in call
Walks through the warning signs for the resident's diagnoses.
7 Days
Check-in call
The same check, a week out. Anything concerning is emailed to your team when a call ends.
~Day 14
CoreQ survey
A separate call: the four CoreQ questions, read word for word, scored on the keypad.
Step 01
Discharge Education
The discharge coordinator opens the resident in TCIQ. Resident details, diagnoses, and family contacts come from the EHR via FHIR; the coordinator reviews the warning signs with the resident and family and captures TCPA consent for the follow-up calls before the resident leaves the building.
Step 02
AI Outreach + CoreQ
TCIQ places automated check-in calls at 48 hours and 7 days post-discharge, then a separate CoreQ Short Stay Discharge survey call at 14 days — three separate calls. Anything concerning is flagged and emailed to the designated escalation contact when the call ends.
Step 03
Review, Documentation & Reporting
Flagged concerns, call summaries, and verbatim transcripts are in the TCIQ dashboard for your staff to review and act on. CoreQ responses are tied to the discharge. Leadership sees follow-up activity, concerns, and satisfaction scores in one dashboard.
Hear a 48-hour check-in call → Hear a CoreQ survey call →
Technical Foundation

EHR-Agnostic. FHIR-Native.

TCIQ reads resident data from your facility's EHR via HL7 FHIR — the open standard supported by the major SNF EHR platforms. No duplicate charting, no proprietary lock-in.

TCIQ is a FHIR Bulk Data application working from the USCDI data set. Our PointClickCare integration is built and running against PointClickCare's sandbox through its USCDI Connector Program, on vendor-agnostic HL7 FHIR designed to extend to other SNF EHR platforms. Infrastructure runs on HIPAA-eligible Microsoft Azure under Microsoft's Business Associate Agreement, with customer-managed encryption keys and PHI kept out of application logs.

HL7 FHIR — EHR Agnostic PointClickCare FHIR Bulk Data Microsoft Azure Microsoft BAA CoreQ Short Stay Microsoft Entra ID Azure Communication Services
FHIR Resources UsedFHIR R4 · USCDI
PatientDemographics, identifiers
RelatedPersonFamily contacts, relationships
ConditionActive diagnoses, ICD-10 codes
MedicationRequestMedication list
EncounterStays and discharge context
Early Access

Built for SNF operators ready for what's next.

TCIQ is built, tested, and ready to pilot at your facility. If you're ready to close the post-discharge gap, reach out.

Request Early Access →
Questions? info@gotciq.com  ·  GoTCIQ.com  ·  Bettendorf, Iowa