Bring transitional care to every hospital and practice in your state.

A statewide program that's already built and operating at national scale — producing reportable outcomes inside the funding window, and sustaining itself after the transformation dollars stop. No EMR project required; each hospital connects in an afternoon.

Start a Digital Backbone Reuse Assessment How it works

Two rural offerings

Two applications. One shared patient record.

Transitional care runs through two peregrine3 applications — one on the hospital side, one in the receiving practice — both working from the same patient record on the 1health network.

Hospital side

Discharge Care Streams

See where every discharged patient goes, and whether they were seen for follow-up. Discharge Care Streams gives your hospital real-time referral and leakage visibility, with automated 30-day follow-up built in.

CMS ADT notification compliance, live on day one.

Runs on the 1health network. No EMR build.

Receiving practice

Primary Care Streams

Run the post-discharge workflow that community primary care usually drops. Primary Care Streams directs follow-up and clears the documentation bar for CMS Transitional Care Management — so the work gets done, and gets paid.

$20k–$40k a year in billable TCM, per practice.

Runs on the 1health network. No EMR build.

Three gaps between funding and results

The dollars arrive. The results are harder.

Interoperability gap

The lengthy last mile

Standard interoperability builds take years, and rural facilities rarely have the local IT staff to configure them.

Operational gap

Readmission risk

When a patient leaves the hospital, the handoff back to community primary care breaks down and slows follow-up — creating blind spots and avoidable readmissions.

Revenue gap

Reimbursement lost

The documentation bar for transitional care management is high, so overwhelmed clinics rarely capture it — leaving reimbursement on the table.

The network

A shared network, run by a neutral party.

Both applications run on 1health — a shared network where an organization joins once and can then coordinate with any other participant, in real time, in any shared workflow. Not another one-to-one interface between two systems.

The network itself is operated by Tachin.ai — a party with no stake in any hospital, practice, or plan on it. So the rules that govern who's who, what's agreed, what's trusted, and how work moves between organizations are the same for everyone. No participant sets the terms for the others, and no one has to connect on a competitor's platform.

Underneath the apps: one canonical patient record — shared meaning, trust, and consent — and a universal connector that accepts HL7, CCDA, FHIR, or PDFs, with no EMR work.

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.

Built for rural

Meets each organization where it is.

Multi-EMR or no EMR

No traditional interface build. The network accepts data in whatever format your EHR already emits — or works with none at all.

Resource-constrained

Built for critical-access hospitals and small practices to join in minutes, alongside larger systems and national plans — no large IT project.

Connect in an afternoon

Feeder hospitals connect with what they already produce. Rollout is one afternoon per site — not a multi-year program.

In production, at national scale

Live today — with the record to show it.

Live across two hospital systems and three national health plans. Two production numbers we keep deliberately separate:

~150,000

Network reach

Providers reached with care-transition notifications across the network.

10,000

App adoption

Providers actively signed in and working transitions inside the applications.

~50,000

Every month

Care-transition records routed to clinics, month over month.

SOC 2 Type II HIPAA attested Transitions-of-Care HEDIS moved 2-Star → 5-Star for a national plan

Illustrative 5–7% fewer 30-day readmissions, by closing the medication-reconciliation gap after discharge — one of the most preventable drivers of avoidable returns. The production figures above are real and verifiable; this readmission range is illustrative, not a promised outcome.

From mandate to go-live

A straight path, on a working clock.

30Days

Assess the fit

A Digital Backbone Reuse Assessment maps your mandate to the pre-built ecosystem and agrees exactly where it fits.

60Days

File for the grant

The submission is filed under your name, with production evidence to cite — not a roadmap, but a system already running.

1Year

Go live statewide

Rollout begins at once. Hospitals connect an afternoon at a time, and reportable transitions start inside the funding window.

Start with a Digital Backbone Reuse Assessment.

We'll map your state's mandate to what's already running — and show you where transitional care can be live inside the funding window.

Request an assessment

References available upon contract negotiation.