Your discharge blind spot is costing you.
During discharge planning, referrals run on phone tag and fax. After the patient goes home, visibility ends — while VBP, hospital partners, and reputation keep score for 30 days. MAXMRJ gives ownership one view from discharge planning through day 30 at home.
*Wheeler et al., JAGS 2025. Readmission rate: CMS SNFRM technical report.
| Building | 4-wk trend | PlacedPlacement rate | Status |
|---|---|---|---|
| Oakridge | 96% | ● Active | |
| Willow Creek | 93% | ● Active | |
| Harbor View | — | ● Inactive | |
| Maple Terrace | 98% | ● Active | |
| Pine Hollow | 88% | ● Active |
Changed since discharge: pain worse · missed a medication. Higher priority for follow‑up.
Illustrative data. Building names are fictional.
“We saved over 50% of our care coordination time.”
median to finalize a referral
of finalized referrals were finalized within 24 hours
Finalized = a community provider accepted the referral, or facility staff finalized it with a provider who marked they can accept.
The discharge blind spot
You can see every admission.You can’t see what happens after you discharge.
Ask how a patient went home last Tuesday and you’ll get a story — not a system of record. Home health, DME, transport, and family communication still often live in phones, faxes, and one person’s memory. Once the patient goes home, ownership has no reliable view of what happens next.
Those thirty days still matter clinically and financially. SNF VBP is funded by a 2% Medicare Part A withhold and anchored on 30-day readmissions — and from FY2027, CMS also scores Discharge to Community. Under CMS’s TEAM model, hospitals are prioritizing SNF partners who can document clean transitions and follow-up.
Medicare patients readmitted to the hospital after a SNF stay.
of SNFs penalized under Medicare’s SNF VBP program in 2024.
hospitals in mandatory TEAM since Jan 2026 — accountable for the 30 days after certain surgeries.
Sources: CMS SNFRM technical report (RTI); Wheeler et al., JAGS 2025; CMS SNF VBP measures; CMS TEAM model.
What MAXMRJ does
From discharge planning through day 30 at home. One workflow for your patients and the 30 days VBP measures.
Works alongside PointClickCare out of the box. No IT work needed. Coordinators learn it in one sitting.
Inside the facility
Discharge planning
- 1
Three clicks to refer
Select the patient and send to home health, hospice, DME, transport, caregiving, and assisted living placement in three clicks — not one call and fax at a time.
- 2
See provider responses in one place
Who has the referral, who accepted, who declined. The entire discharge on one screen instead of in a voicemail box.
- 3
Proof of effort on every discharge
A timestamped record of who you contacted, when, and what they said — what you hand a payer questioning the stay or a surveyor asking whether discharge planning was done. Your staff choose what goes back to PointClickCare as a progress note.
Outside the facility
Post‑discharge
- 4
Check-ins through day 30 (VBP window)
A baseline at discharge, then check-ins by text or email to the patient or caregiver — whoever your team sets. No app or smartphone needed. MAXMRJ provides MaxAlly to families at no charge; your team activates it at discharge.
D0 baselineD1D2D3D7D14D30 - 5
Risk Radar
Our AI analyzes every check-in answer against the patient’s own discharge baseline and tracks the trend across all 30 days — preconfigured and customizable. Patients who need follow-up are identified and prioritized, with the reasons shown — decision support for your coordinators.
- 6
Who to call first
Your team’s call list, in priority order, with the reason next to each name.
For leadership
Every building, one dashboard
Cross-facility metrics for administrators, regional leaders, and executives — for complete portfolio management.
“MAXMRJ optimized discharge processes throughout our facilities…”
The math
Visibility costs less than the blind spot.
MAXMRJ is $350 per facility per month — $4,200 a year — including discharge coordination, post-discharge follow-up, and enterprise reporting. Plug in your portfolio — defaults use our customer’s reported results.
Your portfolio
Coordinators and social services (FTE)
Referrals, confirmations, sending documents, messaging
Conservative default. Our customer reported 50%.
What you pay / yr
Cost- MAXMRJ ($350 × 10 bldgs × 12)
- $42,000
- PointClickCare connection (optional, billed by MAXMRJ)
- $11,880
What you get back / yr
Benefit- Hours spent on coordination today
- 24,960
- Hours returned to your staff
- 8,736 (≈4.2 FTE)
Net annual savings
$282,120
6.2× return on what you pay
From staff time alone.No VBP assumptions in this math.
Estimates only. Excludes the one-time onboarding fee. Time returned is staff capacity, not headcount reduction. Individual results vary; no guaranteed outcomes.
Pricing & pilot
Prove it on five buildings.No subscription for 60 days.
The clock starts at your first discharge — not when IT connects.
Day 1
Invite your community providers
Pick up to five buildings, invite your home health, hospice, DME, and transport partners, and — optionally — submit the PointClickCare connection request. Providers register and onboard over about two weeks; the pilot clock hasn’t started yet.
~Week 2
Pilot starts at first discharge
Your first discharge through MAXMRJ starts the 60-day clock. Referrals and check-ins run on one standard in every pilot building.
Pilot day 30
First ownership report
See which buildings hold the standard and where follow-up is slipping.
Pilot day 60
Your call on group-wide rollout
Decide with your own data, not a vendor case study.
Your day-60 scorecard, by building
- Referrals sent, accepted, and declined
- Discharges with a complete contact record
- Check-ins completed, day 1 to day 30
- Flagged patients followed up
- Time to finalize each referral
- Which buildings held the standard — and which didn’t
Per facility, flat
$4,200 a year. No tiers.
- 60-day pilot on up to 5 buildings — no subscription fee
- Discharge coordination, post-discharge follow-up, and enterprise reporting
- A one-time onboarding fee applies and is covered in your proposal
- Optional $99/facility/mo PointClickCare connection, billed by MAXMRJ
MAXMRJ provides MaxAlly to families at no charge. Your team activates it at discharge.
Questions ownership asks first
No subscription fee for 60 days on up to five buildings, and the clock starts at your first discharge. During the pilot you pay a one-time onboarding fee, covered in your proposal, and, if you use it, the $99/facility/mo PointClickCare connection — both billed by MAXMRJ.
No. PointClickCare is where the chart and the stay live, and it stays your system of record. MAXMRJ adds what PCC doesn’t: discharge logistics with community providers, 30 days of structured post-discharge follow-up, and one ownership view across buildings. Every step is logged, and your staff decide what goes back to PCC as a progress note.
No. Risk Radar is decision support for care teams. It tracks check-in trends over time and against the patient’s discharge baseline so staff know who to follow up with first. It does not diagnose, and patients are directed to 911 or 988 for emergencies.
MAXMRJ provides MaxAlly to families at no charge. Your team activates it at discharge, and it keeps the patient and caregiver connected to your team through day 30.
Just submit the PointClickCare connection request — no development work. MAXMRJ went through PointClickCare’s validation process to become a Certified Development Partner, so the PCC connection is already approved. Your team signs the BAA and picks the buildings.
Less than they do today. Community providers are notified together instead of one call and fax at a time, every step is logged, and Risk Radar tells the team who to follow up with first.
Sixty days.
Your buildings.
Your data.
Every other part of the operation is measured daily. Discharge wasn’t. Start a 60-day pilot on up to five buildings, with no subscription fee. The clock starts at your first discharge — not when IT connects. HIPAA compliant. BAA on Day 1.