Your discharge blind spot is costing you.
Decision support for discharge coordinators, before and after discharge, across your portfolio.
*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, with no system of record behind it. 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 30 days matter for patients and for revenue. SNF VBP is funded by a 2% Medicare Part A withhold and anchored on readmissions within 30 days of hospital discharge — 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
Before and after discharge, through day 30 at home. One workflow for every discharge.
Works alongside PointClickCare out of the box. No IT work needed. Coordinators learn it in one sitting.
Inside the facility
Pre‑discharge
- 1
Three clicks to refer
Select the patient and send to home health, hospice, DME, transport, caregiving, and assisted living placement in three clicks, with every provider notified at once.
- 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, Day 0 to Day 30 after SNF discharge
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 whose answers change move up the call list, with the reasons shown — decision support for your coordinators.
- 6
Who to call next
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 — across your portfolio.
“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 — all features included: pre-discharge referrals, post-discharge check-ins, and portfolio reporting. Plug in your portfolio — defaults use skilled nursing facilities’ reported results.
Your portfolio
Coordinators and social services (FTE)
Referrals, confirmations, sending documents, messaging
Conservative default. Skilled nursing facilities reported 50%.
What you pay / yr
Cost- MAXMRJ ($350 × 10 bldgs × 12)
- $42,000
- PointClickCare connection (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.VBP benefits not added.
Estimates. Annual figures exclude the one-time $2,500/facility setup shown above. Time returned is staff capacity you can redeploy.
Pricing
Simple per-facility pricing.
Live in about two weeks. Cancel anytime.
Day 1
Invite your community providers
Pick your buildings, invite your home health, hospice, DME, and transport partners, and submit the PointClickCare connection request. Providers register and onboard over about two weeks.
~Week 2
Go live
Discharges run through MAXMRJ. Referrals and check-ins run on one standard in every building.
Day 30
Ownership report
See which buildings hold the standard and where follow-up is slipping.
Ongoing
Every building on one standard
Roll out group-wide with your own data in hand.
Your ownership scorecard, by building
- Referrals sent, accepted, and declined
- Discharges with a full contact record
- Check-ins done, day 1 to day 30
- Patients who moved up the call list, followed up
- Time to finalize each referral
- Which buildings held the standard
Per facility · All features included
$4,200 a year
- MAXMRJ platform: $350/facility/mo
- Pre-discharge referrals, post-discharge check-ins, and portfolio reporting
- One-time setup: $2,500/facility, charged at signing
- PointClickCare connection: $99/facility/mo, billed by MAXMRJ
- Cancel anytime
MAXMRJ provides MaxAlly to families at no charge. Your team activates it at discharge.
Questions ownership asks
$350 per facility per month, all features included. The PointClickCare connection is $99/facility/mo, billed by MAXMRJ, and setup is a one-time $2,500 per facility, charged at signing. Cancel anytime.
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.
Risk Radar is decision support for care teams. It compares each check-in with the patient’s discharge baseline, so the people who need a call move up the call list, with the reason shown.
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 the people who need a call move up the call list.
Every discharge.
Your buildings.
Your data.
Every other part of the operation is measured daily. Discharge wasn’t. See it on a demo facility, then go live in about two weeks. HIPAA safeguards and a signed BAA on Day 1. Cancel anytime.