Care Transition  ·  ShiftIQ → VisitIQ  ·  Concept prototype — Sarah Brock, NHA  ·  Fictional patient data throughout
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Prototypes: ShiftIQ → VisitIQ → CarePathIQ →
Care Transition
SNF DISCHARGE → HOME HEALTH START OF CARE
Sunrise SNF → Larimer County HH
SOC  ·  THU JUL 24
Mary Johnson78F · L-Hip Fx Post-ORIF · DNR · Dr. Patel
One episode · three settings · follow the patient
ShiftIQ · Skilled Nursing
Sunrise SNF 201A · Jul 13–24
11 days · 22 shifts · 14 staff
Complete
Care Transition · Discharge
Jul 24 · SNF → home health
5 insights carried forward
You are here
VisitIQ · Home Health
Larimer County HH · Jul 24–Aug 23
Visit 1 of 12 · SOC + OASIS today
Starting today
The same patient. The same intelligence. A different building.
Mary Johnson discharged from Sunrise SNF this morning after 11 days and 22 shifts. Her chart transferred. Everything the staff learned about her almost didn't.
← See her SNF profile See her HH profile →
ShiftIQ  ·  Skilled Nursing
Mary Johnson
78F  ·  L-Hip Fx Post-ORIF  ·  Room 201A
Sunrise SNF  ·  Admitted 7/13  ·  Discharged 7/24
22
Shifts observed
11
Days on unit
14
Staff contributors
Discharge
7/24
VisitIQ  ·  Home Health
Mary Johnson
78F  ·  Post-ORIF recovery  ·  SN + PT
Larimer County HH  ·  SOC today  ·  Visit 1 of 12
5
Insights inherited
0
Visits needed to learn
Day 1
Not a blank slate
Same patient record  ·  Same intelligence layer  ·  Different care setting, different clinician, different questions
The transfer, as it works today
What the discharge packet carries
Standard
DiagnosisL hip fracture s/p ORIF · 7/11 surgery
Weight bearingWBAT · per Dr. Patel
Functional statusAmbulates 45 ft with RW · min assist
Medication listIncludes morphine 5mg PRN q4h
IncisionHealing · staples removed day 9
Code statusDNR on file
Primary MDDr. Patel · (970) 555-0147
What normally disappears at discharge
5 insights lost
Pain reporting patternNot transferred
What actually worked for painNot transferred
Who the real decision maker isNot transferred
Time-of-day mobility patternNot transferred
Help-seeking behaviorNot transferred
Every one of these took the SNF staff multiple shifts to learn. Without a transfer mechanism, the home health clinician relearns all of it, one visit at a time, while the patient is at their highest risk of readmission.
What VisitIQ inherits, and how it translates
Each insight was built from staff observations across multiple SNF shifts. At discharge, VisitIQ carries the pattern forward and rewrites it for the home health context, because the same knowledge answers a different question when the clinician is in a living room instead of a hallway.
ShiftIQ · Pain Pattern
Mary minimizes her pain scores. When she says 4/10, treat it as 6 to 7. She grimaces and guards while reporting a low number. Documented across 6 entries by night and evening CNAs.
Carried forward
Rewritten for
home health
VisitIQ · Pre-Therapy Protocol
Do not time her pre-therapy medication off her self-report. Premedicate 45 minutes before every PT session based on observed pain and scheduled activity, not the number she gives you. If you ask and she says 4, proceed as if she said 7.
Inherited · 6 SNF entries · 22 shifts
ShiftIQ · Intervention Response
Tylenol ES outperformed morphine for Mary. Scheduled acetaminophen produced better reported relief and better mobility participation than PRN morphine, documented across 4 shifts. Morphine left her sedated and less willing to get up.
Carried forward
Med rec
conflict flagged
VisitIQ · Medication Reconciliation Flag
The discharge med list defaults to PRN morphine. The SNF evidence says scheduled Tylenol ES worked better. Raise this with Dr. Patel at start of care, before the first PT session, so the therapy episode starts on the regimen that already worked.
Inherited · 4 SNF shifts · MD contact suggested
ShiftIQ · Family Dynamics
Daughter Patricia is the DNR decision maker, and Mary defers everything to her. Patricia visited twice in 11 days. Mary would not make a care decision without calling her first, including declining a therapy session.
Carried forward
Escalated to
SOC priority
VisitIQ · Establish Contact at SOC
Reach Patricia during the start of care visit, not at the first crisis. She holds the DNR and Mary won't decide anything without her. In the SNF there were nurses on every shift to bridge that gap. At home there is nobody, and the first time you need her will be the worst time to be introducing yourself.
Inherited · 11 days observed · setting-adjusted
ShiftIQ · Behavioral Routine
Mary is meaningfully more mobile in the morning. Afternoon therapy sessions consistently underperformed across the stay. Morning sessions averaged nearly double the ambulation distance of afternoon sessions.
Carried forward
Scheduling
constraint
VisitIQ · Route Scheduling Rule
Schedule every PT visit before noon. This is now a routing constraint on her episode, not a preference. In a SNF the therapy department could flex. In home health the route is built days ahead, so the constraint has to enter the schedule at SOC or it never will.
Inherited · 22 shifts · applied to route builder
ShiftIQ · Help-Seeking Behavior
Mary will not ask for help. She attempted unassisted transfers three times when she believed staff were busy. Twice she was caught mid-attempt. She apologized both times and did it again the next day.
Carried forward
Risk profile
changes
VisitIQ · Home Fall Risk Escalation
Her real fall risk at home is higher than her functional score suggests. In the SNF a call light and a hallway of staff made this behavior survivable. Alone at home it is the single most likely cause of a readmission in the first two weeks. Prioritize the home safety evaluation at SOC and build the environment around the assumption that she will try it alone.
Inherited · 3 documented attempts · risk recalculated for setting
Why it matters, in one episode
Without the transfer
Readmission pathway
Day 1
SOC nurse completes OASIS. Asks Mary about pain. She says 4/10. The pain item is coded low.
Day 2
PT scheduled for 2:30 PM because that's what fit the route. Mary is at her worst. She is not premedicated, because 4/10 didn't warrant it.
Day 2
Session is painful and unproductive. Mary ambulates 18 feet, well under her SNF discharge baseline of 45.
Day 4
Mary declines the session. Says she's tired. The real reason is she remembers Tuesday.
Day 7
Therapy participation is dropping. Deconditioning begins. Nobody has reached Patricia.
Day 9
Mary attempts a transfer alone, because she never asks for help. She falls.
Day 11
ED visit. Readmission. The episode ends 19 days early at a cost of roughly $20,000, and the fall was foreseeable from day one.
With VisitIQ inheritance
Episode holds
Day 1
SOC nurse arrives already knowing she underreports. Pain is assessed by observation and function, and the OASIS item is coded accurately.
Day 1
Home safety evaluation is prioritized on the assumption she will transfer alone. Bathroom and bedside are set up accordingly.
Day 1
Patricia is reached during the visit, not during a crisis. She now has a name, a number, and context.
Day 1
Dr. Patel is called about the morphine versus scheduled Tylenol question, using 4 shifts of SNF evidence as the argument.
Day 2
PT is scheduled at 9:00 AM as a routing constraint. Mary is premedicated 45 minutes ahead.
Day 2
She ambulates 48 feet, ahead of her discharge baseline. She agrees to the next session before the clinician leaves.
Day 30
Episode completes. Twelve visits delivered, functional goals met, no readmission.
The part that isn't clinical
The OASIS start of care assessment is completed in that first visit, and the pain and functional items feed the PDGM case-mix that funds the entire 30-day period. When Mary reports 4 out of 10 and the clinician has no reason to doubt it, the episode gets coded to a lower clinical grouping and a lower comorbidity adjustment, and the agency is now delivering care against a payment that assumes a healthier patient than the one in the chair. The soft intelligence that seems like bedside color is actually reimbursement accuracy. Getting the transfer right protects the patient and the episode economics in the same stroke, which is the argument that gets an agency to adopt this rather than admire it.
The platform argument
ShiftIQ and VisitIQ were never two products. They're one intelligence layer, following the patient.
A post-acute episode crosses three or four settings and a dozen clinicians, and at every boundary the clinical record moves while the understanding stays behind. CarePathIQ plans the episode at discharge, ContinuIQ monitors it across the 30 days, ShiftIQ captures what the SNF staff learn, and VisitIQ carries it into the home. The transition screen is where the thesis stops being a diagram and becomes a patient who didn't fall.
← ShiftIQ · SNF VisitIQ · Home Health → ContinuIQ · Episode → CarePathIQ · Planning →
All patient data is entirely fictional  ·  Concept prototype  ·  Sarah Brock, NHA  ·  2026