The gap
Your outcome is measured
after they stop being yours.
SNFs are measured on a 30-day readmission window, but the real risk doesn't stop on day 31 - a patient can decline at week 8 or month 4 just as easily. Without ongoing visibility, the clinical work you did well gets undone in the silence afterwards.
The post-discharge cliff
A patient leaves with a med list, a follow-up appointment and no support. Adherence collapses within days and nobody knows until the ED calls.
Readmission penalties
SNF VBP ties a meaningful share of Medicare payment to potentially preventable readmissions - driven largely by events you can't currently see.
Referral competition
Hospitals and ACOs steer volume to post-acute partners who can demonstrate low readmission rates. Without data, you're competing on relationships alone.
In-facility blind spots
Between rounds, subtle decline in long-stay residents - appetite, mood, mobility, fluid status - goes unrecorded until it's acute.
The continuous care experience
A patient journey
you don't lose at the door.
The continuous care experience is what keeps a discharged patient connected to your facility - not just for the 30-day readmission window, but for as long as you choose to follow them. Four capabilities make it work.
1Enroll before discharge
→
2Ziva ships & sets up the devices
→
3Continuous monitoring begins
↝
Continuous patient journey
Patients don't disappear after discharge. Ziva follows them from your facility into the home, and stays connected through recovery.
SNF→
Home→
Ziva→
Recovery
⚠
Early deterioration detection
Connected devices and a pillbox stream weight, vitals and adherence continuously, so a concerning trend surfaces days before it becomes a crisis.
Weight +3.4 lb
BP 156/94
SpO2 96%
◈
Clinical intelligence
Isabella connects the dots across vitals, wearables, medications and adherence to surface one clear insight and a recommended action - not raw numbers for your team to interpret themselves.
⇄
Smart escalation & care coordination
Alerts route automatically to the right person - transition nurse, provider, care coordinator or on-call - based on severity and your facility's own workflows.
The connection continues past day 30, so a setback later doesn't mean losing the patient to the system - and for long-stay residents, the same intelligence runs continuously between rounds.
See how Ziva runs transitional care management →How Ziva helps
What changes for
your facility.
The devices and the daily data capture are the mechanics. This is what your administrator, DON and billing office actually get out of it - better recovery outcomes included.
Escalation
Alerts routed your way
You configure who gets notified and how - transition nurse, DON, on-call - so an alert lands with the right person, not a generic inbox.
Follow-up
Reminders and follow-up, handled
Isabella prompts the patient to take daily readings, take medications, and keep follow-up appointments and check-ins - your staff aren't the ones making the reminder calls.
Documentation
A record for every intervention
Every alert, call and outcome is timestamped and logged - the paper trail your VBP quality narrative and compliance file need.
Integration
Fits your existing EHR
Works alongside PointClickCare, MatrixCare, WellSky and others - no separate system for your staff to log into all day.
Alert triage
Critical and pattern alerts, handled differently
A sudden desaturation escalates immediately; a slow weight climb routes as a pattern for same-day review - your team isn't treated to the same urgency for both.
Recovery
Recovery tracked, not assumed
BP, weight, glucose and other vitals trending in the right direction is visible progress - giving your team an evidence-based read on who's recovering well and who's at risk of slipping back.
Impact
Better recovery,
fewer readmissions.
Readmission performance is the currency of post-acute care - it drives payment, referral volume and network inclusion simultaneously. It starts with catching the early signal, not the crisis, and following recovery all the way through.
Earlier
Deterioration detection
Missed medication doses and symptom escalation flagged days before an ED visit
Tracked
Recovery trajectory
Weight, vitals and adherence trends show who's recovering well and who's at risk of slipping
Proactive
Patient engagement
Coaching and reminders delivered the day they're needed, not at the next call
Better
Outcomes & satisfaction
Patients who stay connected and supported recover more consistently and reliably
Directional figures based on published post-acute transition literature and Ziva program modelling; results vary by case mix and transition staffing.
Workflow
How it runs,
day to day.
One continuous operational loop, running in the background of your facility every day - not a separate system your staff manage on top of everything else.
Getting started
Setup, before the loop starts running.
1
Configure your protocols
Set alert thresholds and escalation routing to match how your transition team and on-call already work.
2
Connect your EHR
PointClickCare, MatrixCare, WellSky or your system of record links up so alerts and reports land where your staff already look.
3
Enroll at discharge, and go live
Enrollment happens at the discharge conference; Ziva ships and sets up the devices. The daily loop above starts immediately.
What your staff sees day to day
Progress and alerts, not raw data
Your team gets patient progress updates and alerts to act on, check in on, or follow up - Isabella has already done the watching.
Escalation rules you set
Routing goes to whoever you designate - transition nurse, DON, on-call - configured once at setup, adjustable anytime.
No new software to learn
Alerts and reports surface through your existing system of record wherever integration allows - not a separate portal your staff has to remember to check.
Works with your systems
PointClickCare, MatrixCare, WellSky, American HealthTech and others via HL7 FHIR R4 or structured export.
From devices to decisions
Connected devices in.
A clinical decision out.
Ziva owns the whole chain - ordering, delivery, patient setup, daily data capture, and the interpretation that turns raw readings into something your team acts on.
1
Devices ship to the patient
A connected scale, BP cuff, pulse oximeter and medication pillbox - ordered and delivered by Ziva, pre-configured. No Wi-Fi setup, no Bluetooth pairing.
2
Readings transmit automatically
Weight, blood pressure, SpO2 and pillbox opens sync over cellular every day - no app for the patient to manage.
3
Wearables add another layer
For patients who already use an Apple Watch, Garmin or Oura, Ziva also pulls sleep, heart rate variability and activity - extra signal with no extra device to issue.
4
Isabella builds the pattern
Every reading is compared against that patient's own baseline. A single high reading is noise; converging trends across weight, BP, adherence or sleep are a decision for your team.
Isabella · What's changing this week
Weight+3.4 lb
Home BP (systolic)156 ↑
SpO296%
Diuretic adherence70% ↓
Sleep (via Apple Watch)5.2 hrs ↓
Resting heart rate72 bpm
Isabella · Today's priority
"Eleanor's weight and BP have been rising together for 3 days, with two missed diuretic doses - the same pattern that preceded a readmission for another CHF patient on this unit. Flagged for same-day review."
Fluid retention monitoring
Catch fluid building up
before it becomes an emergency.
Fluid retention in CHF and CKD patients can escalate quickly - from a few pounds of weight gain to shortness of breath within days. Weight and blood pressure rising together is the earliest reliable signal. Isabella tracks both daily, builds each patient's personal baseline, and recognizes when a pattern matches one that has happened before.
✓Daily weight via connected scale — rapid weight-gain alerts calibrated to the patient's own trend, not a generic threshold
✓BP correlated with weight — Isabella flags the combined pattern, not isolated high readings
✓SpO2 monitoring — a drop below baseline can signal early pulmonary fluid, an added layer of protection
✓Medication adherence via pillbox — tagged against the same timeline, so a missed diuretic dose isn't reviewed in isolation
Fluid retention pattern — Eleanor P.*, last 5 days
Systolic BP
↑ 128 → 158
over 5 days
Weight
+3.2 kg
rapid gain
SpO2
94% ↓
from 97% baseline
Medication
68% this wk
↓ from 94% avg
Previous episode — same pattern (March)
Weight gain startedDay -4
BP crossed thresholdDay -2
SpO2 dropDay 0
Diuretic adjusted → resolvedDay +2
Isabella · Pattern alert
"Eleanor's current reading pattern closely matches the fluid retention episode from March — weight up fast, BP rising, SpO2 dropping, and diuretic adherence below 70%. That episode resolved within 2 days once the diuretic was adjusted. Her care team has been flagged."
Beyond the readmission window
Don't lose the patient
to the system. Keep them close.
Readmission reduction is the headline metric, but the real opportunity is longer: an ongoing connection to every patient who leaves your facility. When they stay close through data and alerts, you catch the next decline early, bring them back to your facility instead of a competitor's, and turn a one-time discharge into an ongoing relationship.
Ongoing, not a 30-day program
Monitoring continues for as long as the facility and patient choose - a fluid retention pattern at month 4 gets caught the same way one at day 4 does.
A reason to come back to you
When your facility is the one that caught the problem, you're the one they call and the one the hospital refers back to - instead of losing that patient and that revenue to whoever's left holding the readmission.
Revenue and care, together
Every avoided readmission protects your VBP payment. Every patient who returns to your facility for their next episode of care is volume you didn't have to win back from scratch.
Proof
Continuous care that
made a real difference.
Conditions covered
The diagnoses behind your readmissions.
Heart failure, COPD, pneumonia and diabetes account for the majority of preventable post-acute readmissions. Ziva runs condition-specific protocols for each.
Reimbursement
Payment, penalties
and referral volume.
For SNFs the financial case runs through three channels: the SNF VBP payment adjustment, avoided penalty exposure, and the referral volume that follows demonstrable readmission performance. Where a partnering physician entity bills, RPM and CCM apply to the post-discharge population directly.
SNF Value-Based Purchasing
Medicare withholds a percentage of SNF payment and redistributes based on readmission performance
Payment adjustmentDirectly tied to potentially preventable readmission measures
Ranking effectPerformance is scored relative to peers — improvement compounds
DocumentationContinuous post-discharge monitoring records support your quality narrative
RPM — 99453 / 99454 / 99457 / 99458
Device-based physiologic monitoring, 16+ transmission days per month
99453One-time setup & patient education — ~$19
99454Device supply + daily transmission — ~$46/mo
99457First 20 min interactive care management — ~$48
99458Each additional 20 min — ~$39
CCM — 99490 / 99439
Patients with two or more chronic conditions expected to last 12+ months
99490First 20 min clinical staff time / month — ~$62
99439Each additional 20 min — ~$47 (up to 2×)
Ziva's time logs, monitoring records and monthly reports supply the documentation these codes require. Confirm eligibility and rates with your billing team and MAC.
Program revenue estimate
Short-stay discharges / month
45
5monthly discharge volume200
Program type
Device supply (99454)—
First 20 min (99457)—
Additional 20 min (99458)—
Estimated monthly program revenue
—
— annually
Illustrative national-average estimates. Actual reimbursement varies by MAC, locality, payer mix and documented time.
Get Started
Bring readmission data
to your next hospital meeting.
Send us your discharge volume and readmission rate and we'll model the post-discharge program, the VBP effect and the reporting you'd be able to show referral partners.
✓Readmission impact model for your discharge volume
✓SNF VBP payment adjustment scenario
✓Transition-team workflow and alert volume design
✓Referral-partner reporting package
Request a 30-minute demo
We'll walk through enrolment, alert configuration, and the revenue model for your practice.
Book my demo →No commitment. We'll follow up within 1–2 business days.
Security & compliance
Built for healthcare.
Trusted by clinical teams.
Ziva was designed from the ground up for clinical environments - not adapted from a consumer app. Every data flow, access control, and integration meets the standards your compliance team requires.
🔒
HIPAA compliant
BAA available. All PHI encrypted in transit and at rest.
✅
End-to-end encrypted
All PHI encrypted in transit and at rest. HL7 FHIR R4 compliant data exchange.
🏥
US data residency
All patient data stored and processed within the United States.
📋
Audit-ready logs
Consent records, access logs, and billing documentation stored and exportable.
Questions
Skilled nursing FAQ
Most post-acute readmissions follow a visible trajectory: weight or vitals drift, medication doses are missed, symptoms escalate over several days. Connected devices and a pillbox stream that data continuously, and Isabella - the intelligence layer - flags the pattern to your team while it's still a phone call, not an ER visit. This works whether the setback happens on day 5 or month 3.
Facilities configure this. Most route alerts to a transition nurse, care coordinator or the receiving primary care provider. Isabella is the intelligence layer that turns continuous device and pillbox data into that alert - the clinical decision and response stay with your team and the provider.
Directly, only if your organisation includes or partners with a billing physician entity - in which case RPM and CCM apply to the discharged population. For most SNFs the financial case is the SNF VBP payment adjustment, avoided readmission penalty exposure, and referral volume, rather than fee-for-service revenue.
Ziva's program is ongoing, not a 30-day product. The 30-day readmission window is one measured outcome, but the monitoring relationship continues for as long as the facility and patient choose - so a setback at week 8 or month 4 is caught the same way one at day 4 is, and the patient stays connected to your facility instead of to whoever picks up the readmission.
Isabella reminds each patient to take their daily readings on schedule - weight and blood pressure for cardiac and readmission-risk patients, glucose for diabetic patients, SpO2 for respiratory patients, plus medication doses from the connected pillbox. Reminders repeat and escalate to a check-in call if a reading is missed, so gaps in the data get caught, not just gaps in care.
Yes. Fully HIPAA compliant, with a BAA available for your facility. All PHI is encrypted in transit and at rest, data is stored within the US, and every alert, call and access event is logged for your compliance file.
PointClickCare, MatrixCare, WellSky, American HealthTech, Netsmart and others via HL7 FHIR R4 or structured export. Where direct integration isn't available, Ziva provides a standalone portal with PDF and CSV export for the record.