Clinical and financial visibility
across every facility.
Real-time visibility into telehealth utilization, billing performance, call activity, and coding patterns. Turn your remote care operation into measurable operational insight.
Enterprise Clinical Analytics for the most innovative PALTC operators
This interactive prototype shows operator-level analytics. Scroll within the dashboard to explore billing metrics, call patterns, ICD code frequency, and revenue breakdowns.
Total calls
Billable, non-billable and unanswered calls
Median calls count
Break down per day of the week
ICD codes frequency
Top recurring ICD codes
Revenues breakdown
Billing codes shares
Provider utilization & coverage gaps
Call volume and unanswered rate by hour
Case resolution
AI-inferred resolution category
Repeat consultation rate
30-day repeat rate by diagnosis group
Avg. time to note completion
By provider — operational visibility, not performance judgment
Rehospitalization Lens
Correlation view, not causal attribution
Data reflects the last 14 days. Resolution categories are AI-inferred from clinical notes and may not reflect official disposition. Rehospitalization correlation is observational, not causal. Provider note timing is for operational awareness, not individual performance evaluation.
AI-Powered Operator Insights
Recommended actions generated from facility, provider, documentation, and quality signals.
- •2a-4a unanswered rate is highest
- •Closed-loop follow-up completion: 71%
- •Median provider response: 18 min overall, worse overnight
Escalation gaps can create unresolved changes in condition and inconsistent provider communication.
Audit overnight routing and confirm whether follow-up documentation is completed after provider response.
- •Eligible events: 420
- •Provider encounters: 386
- •Note complete: 354
- •Documentation leakage: 32
- •Estimated recoverable value: $18.6k
If documentation lags, billing and coding workflows also lag.
Review providers over the 60-minute note completion target and prioritize note-completion intervention.
- •Function / GG support: 73%
- •SLP-related conditions: 76%
- •Evidence gaps due in 48h: 11
- •Overall evidence readiness: 84%
Missing evidence before the assessment window can create downstream documentation and case-mix risk.
MDS Coordinator reviews residents due in 48h and requests missing nursing/provider documentation.
- •Pressure injury score: 69
- •Weight loss / nutrition score: 67
- •Falls / injury score: 72
- •Three review domains flagged
These domains often require coordinated nursing, provider, therapy, and administrative follow-up.
Create a QAPI review list and confirm wound/nutrition/fall interventions are documented.
Change-in-Condition Closed-Loop Rate
From nurse concern to provider response to documented follow-up
Provider Visit Coverage & Follow-Up Gaps
Required visits, acute callbacks, and high-risk follow-ups by facility
| Facility | Required visits | Acute callbacks | Hospital-return | High-risk reviews | Notes signed |
|---|---|---|---|---|---|
| Pine Valley SNF | 96% | 91% | 89% | 84% | 94% |
| Oakridge LTC | 88% | 79% | 76% | 72% | 86% |
| Sunrise Care Center | 93% | 87% | 85% | 81% | 90% |
| Meadowbrook Rehab | 84% | 73% | 69% | 68% | 82% |
| Hillcrest Post Acute | 91% | 86% | 83% | 78% | 88% |
Visit-to-Claim Revenue Integrity
Track leakage from clinical work to submitted claim
MDS / PDPM Evidence Readiness
Documentation support before assessment windows close
QAPI / Five-Star Early Warning Radar
Leading signals across quality, safety, and care coordination
I-SNP AI Management Insights
Carebrain reviews member, facility, provider, transition, and documentation signals to suggest where the I-SNP team should look next.
- •17 members with open transition gaps
- •9 have medication changes not fully reconciled
- •6 have hospital PDF diagnoses not reflected in GEHRimed / PCC problem lists
- •5 have new orders not yet confirmed in PCC
Executive view: transition gaps raise utilization and quality risk. Clinical manager view: flags hospital-return residents needing reconciliation review. Frontline nurse view: clarifies med / order changes that must be verified before the shift ends.
Work the reconciliation queue for hospital-return members, starting with medication and new-diagnosis changes.
- •12 high-risk members without a recent provider touchpoint
- •5 have worsening intake or weight trend
- •4 have repeat respiratory / CHF consults
- •3 have recent fall or wound documentation
Executive view: proactive touchpoints can reduce avoidable urgent utilization. Clinical manager view: creates a focused rounding list. Frontline nurse view: shows which residents are likely to need provider review soon.
Build a same-week NP rounding list from the high-risk members with the oldest last-touchpoint dates.
- •Overall MOC readiness: 91%
- •New-member MOC readiness: 78%
- •8 HRAs due within 7 days
- •11 ICP care-plan tasks unresolved · 6 ICT reviews pending
Executive view: shows operational execution of the I-SNP care model. Clinical manager view: identifies new-member care-planning gaps. Frontline nurse view: clarifies which resident baseline and care-plan details still need completion.
Hold a weekly new-member huddle to clear HRA, ICP, and ICT tasks for recent enrollees.
- •HCC evidence readiness: 82%
- •14 suspected diagnosis evidence gaps
- •7 hospital PDF conditions not found in GEHRimed active assessment
- •5 PCC problem-list mismatches
Executive view: supports member acuity visibility and documentation integrity. Clinical manager view: prompts provider review of clinically supported conditions. Frontline nurse view: prevents important hospital diagnoses from being missed during transitions. This surfaces documentation gaps for provider review and is not coding advice.
Route suspected conditions to the provider group for review and confirmation before the next visit.
Member Panel & Eligibility Funnel
Track institutional eligibility, enrollment capture, and facility-level panel opportunity
Mock data. "Likely eligible" reflects census and facility status, not a final enrollment determination.
Model of Care Execution
HRA, individualized care plan, ICT review, medication review, and follow-up completion
Care-model execution across HRA, care plan, ICT, medication review, and follow-up. Mock data.
Provider Touchpoint & High-Risk Coverage
Proactive NP / provider coverage for members most likely to escalate
Risk drivers are signals for proactive review, not AI diagnoses.
Care Transition Assimilation
Hospital record changes reconciled into PCC, GEHRimed, and Carebrain workflows
- New: Eliquis 5mg BID
- Dx: Acute CHF exacerbation
- Follow-up: cardiology recommended
- MAR updated
- Problem list pending
- Follow-up not yet scheduled
Diagnosis review gaps appear in hospital summaries but are not yet confirmed in GEHRimed or the PCC active problem list.
Treat-in-Place Opportunity
Review avoidable-transfer patterns by condition group, facility, and response pathway
"Reviewable transfer" indicates an opportunity for operational review, not certain avoidability.
Risk Adjustment Evidence Readiness
Supported diagnosis evidence across hospital records, PCC, and provider documentation
Shows evidence readiness and where provider review is needed — not coding or RAF advice.
Medication & Pharmacy Risk Review
Med changes, high-risk medications, reconciliation gaps, and review completion
Items are flagged for review; Carebrain does not make pharmacy decisions.
Silent Decline Watchlist
Subtle multi-day changes that may deserve proactive review — a review aid, not a diagnosis
A multi-signal trend that may deserve review — not a diagnosis or prediction of decline.
I-SNP Program Signal Summary
- • Member panel metrics use mock enrollment and PCC census context.
- • Transition assimilation compares hospital PDF summaries against PCC, GEHRimed, and Carebrain workflow events.
- • Risk evidence readiness surfaces documentation gaps for provider review; it is not coding advice.
- • Silent Decline Watchlist is a multi-signal review aid and not a diagnosis.
- • Mock data shown for demo purposes.
Enterprise Command Center
A unified view of your remote care program. Track total billing, call volume, wait times, and per-provider performance across all facilities from a single dashboard.
- KPI summary: billing totals, call counts, duration metrics
- Stacked call volume by billable, non-billable, unanswered
- Weekly call distribution radar chart
- Top ICD codes by frequency
- Revenue breakdown by billing code
Move from anecdotal management to measurable insight
Call Activity Visibility
See billable, non-billable, and unanswered calls across your entire operation. Identify patterns and optimize provider coverage.
Billing Performance
Track total billing, average bill per visit, and revenue by billing code. Understand which services drive the most value.
Coding Trends
Monitor ICD code frequency to spot clinical patterns. Ensure documentation captures the full complexity of encounters.
Wait Time Metrics
Monitor median call duration and wait times. Optimize scheduling and ensure timely patient access to care.
Standardized Operations
Enterprise-grade visibility enables consistent protocols and performance benchmarks across all facilities.
Financial Outcomes
Data-driven insight into reimbursement performance helps identify opportunities and improve financial outcomes.
Your operation.
Fully visible.
See how Carebrain gives SNF operators enterprise-grade visibility into their remote care programs.