Hospital Care Streams on the 1health network
Connect your discharges to the rural PCPs who receive your patients. When those patients need imaging, a procedure, or a specialist, their PCP refers them back to you in one click. Continuity for the patient, referral intake for your hospital, and no EMR project to get there.
Run a rural practice or a health plan? The same circle works for you: Primary Care Streams for practices, Transitional Care Streams for plans. Leading a state rural health program? See the view for states.
The space between organizations
Records got better. The work between organizations didn't. And discharge is where it breaks first.
How it works
The connection that sends your discharge out to the patient's PCP is the same one that brings her referral back to you. Follow one patient around it.
Your ADT fires at discharge. Her rural PCP gets the notice with records attached, and you can see where she went next.
The practice runs the 7-, 14-, and 30-day follow-up and the transitional-care documentation, so the visit gets done and gets billed.
Her health plan watches the transition in real time and closes HEDIS and Stars gaps without adding work for the practice.
When she needs imaging, a procedure, or a specialist, the PCP refers her back to you in one click. The referral lands in your intake, gets scheduled, and the result flows back to the PCP.
A patient who leaves your network isn't lost. The relationship you built coordinating her discharge is the reason she comes back the next time she needs care only you provide.
For hospitals
Hospital Care Streams has two parts. Connecting your discharges is table stakes: useful, required, and not enough on its own. The return comes from what that connection makes possible — a one-click path from every connected PCP back to you.
Connect your ADT feed once. Every discharge routes to the receiving PCP with records attached, and a closed-loop view shows you, per patient, whether follow-up was scheduled and completed, whether transitional care was billed, and whether she came back within 30 days.
For the PCP, it's one click to refer back to your hospital, inside the same tool they already use for your discharges. For you, it's a full intake workflow: the referral arrives with the record, is triaged and matched to the right service line, gets scheduled, and closes back to the referring PCP with the result.
Why referrals come back
On 1health, that path leads back to you.
Same patient, same record, same episode. Sending her back to the team that just cared for her is the safest choice for her, and the PCP knows it.
The referral starts inside the tool the PCP already works in for your discharges. No fax, no phone call, no new portal to learn.
You define the routes into your specialists and service lines, so the PCP always knows where to send her and what happens next.
Sharing your discharges doesn't invite leakage. It builds the relationship that pulls the next referral back in — a network of connected practices that reaches well beyond your CIN.
For rural practices
Primary Care Streams puts every discharge for your patients in one list, with the records attached and the follow-up clock already running. The work gets done, gets documented, and gets paid.
For health plans
Transitional Care Streams gives your care coordinators one live board of every member moving through a care transition, opened by the hospital's ADT and updated as the PCP follows up. HEDIS and Stars gaps close without chasing providers or members.
Neutral ground
Thirty years of strong EHRs, data platforms, and repositories mean every organization has a system of record. What's been missing is a way to act across them: one shared place where a hospital, a practice, and a plan coordinate around the same patient.
That place is 1health, operated by Tachin.ai — a party with no stake in any hospital, practice, or plan on it. The rules for who's who, what's agreed, what's trusted, and how work moves are the same for everyone. No participant sets the terms for the others, and no one connects on a competitor's platform.
Underneath the apps: one canonical patient record and a universal connector that accepts HL7, CCDA, FHIR, or PDFs — multi-EMR or no EMR, with no interface build. Each organization's data stays its own.
Point-to-point interfaces and in-house exchanges work — but every new relationship is another build, owned by whoever built it. A shared, neutrally run network is built once and open to all.
Proven at enterprise scale
Live with three national health plans and three major health systems. Every seat in the circle is running now.
Getting live
No rip-and-replace and no multi-year EMR project. Critical-access hospitals and small practices join the same way large systems do.
Your hospital self-onboards and connects its ADT and records feed, alongside the systems you already run.
Rural practices register and load their patient lists. Your discharges reach every connected PCP, and follow-up automation begins.
Your care pathways are defined, referral intake is live, and referrals from connected PCPs flow back into your schedule.
Hospitals connect a feed in an afternoon. Practices and health plans join the same network, and the full circle is live in 90 days.
For state rural health programs
Roughly half of your Rural Health Transformation award is rescored every year on what you can demonstrate. We put the workflows your plan already funded into production in 90 days, on the systems your rural providers already use, and record every action so the evidence behind your outcomes is ready when you report.
Run a hospital, rural practice, or health plan? See the view for providers & plans.
Why in-year proof matters
Rural Health Transformation is a performance-based program. What your state can show this year shapes what it receives next year.
What we do
The program's own rules favor extending systems over replacing them: EHR replacement is capped at 5% of a state's award where a certified EHR is already in place. We work the same way.
Your HIE, data backbone, and connectivity projects keep building underneath. Cross-organization workflows run on top of them now, with no rip-and-replace.
Each referral, notification, visit, and handoff is logged with who acted, when, and on whose record, so your outcomes rest on event-level records.
Transitional care follow-up is billable, so the workflow brings rural practices revenue that continues after program funding ends.
Workflows your plan can fund
Each deploys in 90 days and is configured to your approved initiatives. In a state-funded network, rural providers join at no cost.
A structured consult workflow from rural hospitals to specialist hubs: a complete clinical packet, urgency-triaged routing, a documented recommendation, and a view of the patients managed locally.
ADT-triggered follow-up across hospitals, rural PCPs, and health plans: records reach the PCP, follow-up is tracked to its window, medication changes surface, and the plan sees the gap close.
Consults, referrals, care transitions, shared care plans. If your initiative depends on organizations working together, it can run as a shared workflow on the same network, configured during the 90-day deployment.
What you can report
The network logs each step with who acted, when, and on whose record. That event-level trail is the evidence behind the outcomes you report to CMS.
| What happens | What's on record | What it supports |
|---|---|---|
| A rural hospital requests a consult | Time to recommendation, the documented disposition, and whether the patient stayed local | Access and keep-care-local measures |
| A patient is discharged | PCP notified, follow-up scheduled and completed within its window | Transitions-of-care and follow-up measures |
| A practice completes transitional care | Documentation for billable transitional care management | Provider sustainability beyond program funding |
| Anyone acts on the network | Who acted, when, on whose record, with provenance | Performance records available for CMS review |
How states fund it
Use the path that matches how your plan distributes funds.
Your agency contracts for a statewide workflow tied to an approved initiative, and rural providers join the network at no cost.
Your hubs, anchor hospitals, and regional networks include the workflow and its reporting in their subawards.
Plan-side transition workflows can be added through your existing managed care contracts.
Whichever path you use, every organization joins the same neutrally run network. A hub's workflow and your statewide evidence trail stay connected instead of splintering across separate tools.
Already in production
Live with three national health plans and three major health systems.
Tell us which initiatives you're deploying and what you report on. We'll show you which workflows can be live, and on record, before your next annual report.