Success Story
About the Client
Elite Care, a US-based transitional care provider, enhances post-acute patient care through advanced technology. Its platform streamlines Transitional Care Management (TCM) by connecting providers in real time, improving communication, and ensuring smooth, patient-centered care transitions for diverse stakeholders.
Business Situation & Requirements
Nearly 20% of Medicare patients are readmitted within 30 days of discharge, often due to poor care coordination after discharge from the hospital. Structured Transitional Care Management (TCM) programs can reduce readmission risks by 50–60%, highlighting the urgent need for streamlined, technology-driven care transitions.
Elite Care, a US-based transitional care provider, faced similar challenges, including hospitals operating in silos, limited communication with primary care physicians, delays in scheduling follow-ups, and inefficiencies in medication reconciliation. These gaps made managing TCM complex and resource-intensive, underscoring the need for a comprehensive, end-to-end platform to ensure seamless, safe care transitions.
To navigate these challenges, Elite Care sought a technology partner to build a holistic platform that would equip healthcare providers with accurate patient data, enable timely follow-ups and interventions, and streamline transitional care tasks. The solution was designed to improve care quality, reduce readmissions, and ease administrative burdens, allowing providers to focus more on patient-centered care. To bring this vision to life, Elite Care partnered with Unthinkable to accelerate the development of a scalable, market-ready TCM solution.
Key Requirements:
Conduct an initial discovery phase to understand requirements, workflows, and challenges before designing the TCM solution.
Design and develop the solution end-to-end, including UI/UX, architecture, development, and testing, using an efficient technology stack.
Build a robust architectural framework that supports platform functionality and allows rapid deployment.
Create user-friendly portals for practice and facility management to streamline tasks and manage patient information effectively.
Enable seamless interoperability between different EHR systems for smooth data exchange.
Ensure compliance with healthcare regulations and standards, such as HIPAA, and complete the project within 15 weeks.
The Solution
Team Unthinkable adopted a strategic, architecture-first development approach powered by its proprietary project management platform, Locomo. At the outset, the team defined the solution’s top-level architecture and decomposed the application into well-structured, decoupled modules. This clarity enabled requirements to be documented as detailed user stories, creating a focused and organized roadmap while maintaining alignment with the overall system vision. Simultaneously, the team designed intuitive UI/UX components to ensure healthcare providers could seamlessly navigate the platform, access critical patient data, and manage care tasks efficiently.
Leveraging Locomo’s built-in visual tools, including automated ER diagram mapping, the team accelerated development by clearly outlining component relationships and interactions. By aligning schemas and APIs, they strengthened interoperability and enabled seamless integrations with EHR systems such as AdvancedMD. Coupled with Locomo’s automated testing framework embedded within structured release cycles, this approach ensured early issue detection and performance optimization, ultimately delivering a compliant, reliable, and high-performing transitional care management platform.
Enhancing patient management through EHR integrations
A key driver of the platform’s effectiveness was its integration with Redox, enabling secure, seamless data exchange across EHR systems such as AdvancedMD. Through Locomo, the team automated patient data synchronization at discharge and every 7 days after creation. This ensured up-to-date access to admissions, diagnoses, medications, and transition details, empowering practice admins to make informed decisions and maintain accurate patient records.
Ensuring a compliance-focused journey for our client
To build a HIPAA-compliant platform, Team Unthinkable implemented end-to-end encryption to protect patient data at rest and in transit. Role-based access controls restricted sensitive information to authorized personnel, while two-factor authentication added an extra layer of security. Regular security audits were conducted to proactively identify vulnerabilities, ensuring continuous compliance and safeguarding patient information across the platform.
Enabling seamless TCM with the development of admin portals
Leveraging Locomo’s modular architecture, Team Unthinkable developed comprehensive Facility Admin and Practice Admin portals to streamline transitional care management. These portals centralized operations, improved coordination, and ensured the timely execution of care tasks while maintaining compliance and visibility across patient journeys.
Dashboard: Care & Task Overview
The dashboard serves as a centralized command center, offering real-time visibility into patient transitions and active care tasks. It tracks TCM completion over the last 30 days, marking encounters complete when tasks are finished within 14 days, or flagging them as missed to identify gaps and improve outcomes.
Facilities: Patient Allocation & Coordination
The Facilities module provides a structured view of associated healthcare centers, enabling smooth coordination between inpatient and outpatient settings. It simplifies patient allocation, supports seamless data flow across care environments, and ensures continuity during transitions, reducing administrative friction and improving operational clarity.
Chat: Secure Internal Messaging
The internal chat feature enables real-time collaboration among care team members. By centralizing communication within the platform, it minimizes delays, enhances coordination, and ensures that important patient-related discussions remain documented, secure, and easily accessible to authorized users.
Tasks: TCM Activity Tracker
The Tasks module automates the assignment and tracking of critical transitional care activities such as medication reconciliation, scheduling follow-ups, and conducting post-discharge check-ins. It ensures accountability by monitoring deadlines and status updates, helping teams complete all required actions within prescribed timeframes.
Admin: User & Access Control
The Admin panel allows role-based user management, access control configuration, and system customization. It ensures that only authorized personnel can access sensitive information while maintaining flexibility to adapt workflows, permissions, and operational settings according to organizational requirements.
Patient Chats: Care Coordination
Patient Chats provide secure, patient-specific communication channels for care teams. This feature supports follow-up discussions, clarification of treatment plans, and ongoing care coordination while maintaining privacy and compliance standards, ensuring consistent engagement throughout the transitional care process.
Alerts: Critical Care Updates
The Alerts system delivers time-sensitive notifications to relevant roles, ensuring prompt action on pending tasks. For example, care teams receive reminders when tasks are due within 24 hours, reducing the risk of missed interventions and supporting the timely completion of transitional care requirements.
TCM Note: Downloadable Care Records
Once TCM activities are completed, the platform generates a downloadable PDF summary note. This document captures all completed tasks and related discharge details, supporting accurate documentation, billing processes, and audit readiness while providing a consolidated overview of post-discharge care efforts.
The Impact
Unthinkable delivered a robust, HIPAA-compliant TCM platform in just 15 weeks by adopting an architecture-first approach that accelerated feature releases by nearly 50%. This rapid development cycle enabled faster time-to-market while ensuring reliability, performance, and seamless care coordination for healthcare providers.
Powered by Locomo, the solution enhanced interoperability, reduced readmission risks, and streamlined administrative workflows. Beyond addressing immediate operational needs, the platform established a scalable, patient-centric foundation that supports long-term growth and continued innovation in transitional care management.
