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SentioWeb TCM
30-day transitional care management for
post-discharge monitoring and readmission prevention
SentioWeb TCM helps care teams monitor patients after discharge, prioritize readmission risk, coordinate follow-up and intervene earlier during the highest-risk 30-day window.
Reduce avoidable readmissions
Catch early signs of decline and act before complications lead to returns to the hospital.
Prioritize
high-risk patients
Use risk scores and trends to focus resources where they matter most.
...
Coordinate post-discharge outreach
Ensure timely calls, education, medication reviews, and follow-up across the care team.
The 30-day transitional care workflow
Track vitals, symptoms, and engagement signals during the critical 30-day window.
Patient monitoring
Risk Stratification
AI-powered risk scores identify patients most likely to return so you can intervene earlier
Outreach & follow-up
Automate outreach cadence and tasks to keep patients connected and informed.
Documentation & coordination
Capture interactions, update care plans, and keep the team aligned in one place.
Why SentioWeb TCM?
Secure, scalable, and interoperable across care settings.
Built on the
SentioWeb platform
Integrates with
RPM / CCM workflows
Seamless handoffs, and shared patient context.
Designed for clinical operations
Practical tools that fit real-world care team workflows.
AI-ready
by design
AI co-pilot reduces administrative overhead burden
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