Post-Discharge Care Coordination for Skilled Nursing Facilities
The Landing System for
Skilled Nursing Discharges.
The EHR manages the flight. MAXMRJ manages the landing.
Your coordinators' 30-60 minute referral process — done. Free to start. No credit card. No IT project.
Post-Discharge Follow-Up
Certified Partner
Don't Fly Blind.
Once they discharge, they fall off your radar.
Nearly 1 in 5 patients are readmitted (Crash).
Readmission Risks lead to CMS Penalties and reduced VBP reimbursements—protect your facility with post-discharge care coordination software.
Clear the Fog.
Land Safely.
How MAXMRJ Prevents SNF Readmissions
MAXMRJ acts as the Landing System for post-acute care. We merge discharging patients and community resources into a single visibility layer.
Care Traffic Control
Discharge Logistics Coordination
Coordinate Nursing, DME, and Transport from one command tower. Eliminate phone tag forever.
Risk Radar
Proactive AI Risk Analysis
After discharge, automated surveys go to patients or caregivers. AI analyzes responses over time to flag potential concerns before they become emergencies.
Provider Network
Community Provider Coordination
Connect directly to community providers ready to serve your discharged patients.
From Discharge to Done in 4 Steps
Replace 30-60 minutes of phone tag with a streamlined digital workflow.
Patient Selected from PointClickCare
Patient details and discharge information flow automatically. No re-entering data.
Choose Providers — One Click
Select from your network: home health, DME, transport, hospice. All notified simultaneously.
Providers Respond and Coordinate
Providers accept, share documents, coordinate in MAXMRJ. Full visibility for your coordinator.
Follow Up After DischargeAI Add-on
Automated surveys go to the patient or caregiver at home. AI analyzes responses over time to flag potential concerns — and gives your coordinator specific recommendations.
What VBP Penalties Are Costing You
CMS withholds 2% of your Medicare revenue and redistributes based on quality. 72% of SNFs received penalties in 2024.
Readmissions account for 40-50% of your VBP score.
Source: CMS SNF VBP Program public data. Individual results vary by facility.
The Math That Matters
A 100-bed SNF with ~$150K in annual VBP penalty exposure.
Average cost of one hospital readmission: $15,000 – $25,000 (MedPAC).*
MAXMRJ AI follow-up: $199/month = $2,388/year.
If post-discharge check-ins help prevent even 2 avoidable readmissions per year, that's $30,000 – $50,000 in potential savings.
The base platform is free. You're only paying for the AI follow-up that helps catch problems before they become readmissions.
* Average Medicare readmission cost per MedPAC. Individual results vary. MAXMRJ does not guarantee specific readmission reduction outcomes.
Why MAXMRJ (Not Another Feature Inside Your EHR)
Your EHR (e.g. PointClickCare)
- Manages the patient while they're in your facility
- Tracks data inside your walls
- No post-discharge coordination or follow-up
MAXMRJ (After They Leave)
- Coordinates the 2-5 external providers your patient needs at home
- Checks in with patients and caregivers after discharge
- AI flags concerns early so your team can act
These are different problems. They need different tools. That's why we integrate WITH PCC, not compete against it.
“We already have social workers calling patients after discharge.”
Great — MAXMRJ doesn't replace that relationship. It makes it systematic.
Instead of calling 30 discharged patients and hoping to catch problems, your coordinator sees exactly which 5 patients need attention today.
The human touch stays. The guesswork goes.
Hospitals Are Now Choosing SNFs Based on Outcomes
Under CMS's TEAM Bundled Payment Model, hospitals own the financial risk for 30 days after discharge — including everything that happens at your SNF and after. They'll partner with facilities that can prove good outcomes.
What Changed
Under TEAM, CMS bundles payment for the entire episode — from surgery through 30 days post-hospital discharge. If a patient goes to your SNF and then gets readmitted to the hospital, the hospital pays the price.
That means hospitals are now actively evaluating which SNFs to partner with. Facilities that can demonstrate smooth transitions and strong post-discharge follow-up become preferred referral partners. Facilities that can't? They lose referrals.
Nearly 0%
of SNFs have a systematic post-discharge follow-up system
30 days
Hospitals now own the financial risk post-discharge — your outcomes are their outcomes
80% off
Early-adopter rate: $199/mo locked through 2028 (standard: $1,000/mo)
A Day in the Life of Your Coordinator
See how MAXMRJ transforms the discharge workflow.
Protect Your VBP Scores.
Help prevent readmissions by standardizing your discharge logistics.
Upgrade Your Intake.
Get listed in SNF networks and receive referrals directly. AI-powered intake summaries help you process referrals faster.
What Our Partners Say
“MAXMRJ cut our referral process from over an hour to just a few minutes.”
Director of Social Services
200-bed SNF