Prepared Provider Series · For Hospitals & Care-Transition Teams

The problem hospitals pay for twice. The asset that solves it once.

The Care Transitions Credential turns standardized 30/60/90-day discharge planning into a documented readmission intervention and a stackable, accreditation-ready nursing credential — funded from two budget lines, delivered as one guided, TurboTax-style builder in Dr. Rob's plain-spoken voice.

See the business case → ▶ Try the builder
Dr. Rob
Your host: Dr. Rob. "A discharge is like sending someone off on a road trip. We don't just wave goodbye at the door — we check the tires, fill the tank, and tell them where the rest stops are. This builds the map and names who's waiting at each stop."

One asset. Two budget lines.

The work that reduces readmissions is the same work that develops and credentials staff. We packaged them together.

Quality / Pop Health

A documented readmission intervention

A standardized, timestamped 30/60/90-day intervention against avoidable 30-day readmissions — with a built-in follow-up loop and completion records you can point to in a quality review. Someone finally owns the arc from the building to the home.

Workforce Dev

A credentialed upskilling path

A stackable, accreditation-ready credential for nurses, paramedics, community health workers, and home-PT staff — tied directly to the outcomes you're already trying to move, instead of disconnected from them.

➕ A third internal line: the routing engine surfaces social drivers of health and assigns a CHW to address them — a documented, fundable health-equity intervention. The Sickle Cell cluster doubles as health-equity / DEI training.
The defensible piece

The routing engine: match the modality to the barrier

Most discharge plans say "follow up." Ours says who, when, and why — matching each 30/60/90-day window to the modality that fits the patient's clinical and social profile. That's the hard-to-copy part, and it's what turns a piece of paper into a recovery.

Live
🩺

Visiting Nurse

In-home assessment, weights, med reconciliation, teach-back.

Live
🤝

Community Health Worker

The social barriers no prescription fixes: transport, food, isolation.

Live
🦿

Home Physical Therapy

Mobility, strength, and fall-prevention in the home.

Expansion
🚑

Community Paramedicine / MIH

In-home acute check between the visiting nurse and the ED. Taught in full depth.

Expansion
💻

Telemedicine / RPM

Structured remote contacts + device monitoring. Strongest fit for heart failure.

Three modalities are wired into the builder today; two are shown as expansion-ready so the roadmap is visible without overpromising. All five are taught in full depth in the foundation course, so providers can instruct on every option.

What's inside

Three layers, built to scale per condition

A condition-agnostic SHELL builder cloned per condition — the same way our Prepared Patient catalog scaled to thirteen conditions. The hospital gets a whole library from one validated design.

The Tool · Applied

Care Transitions Builder

A 12-step guided flow: Assess → Plan (30/60/90) → Route (5 modalities) → Verify → Knowledge Check (80%) → Credential → Share It. Gamified, in Dr. Rob's voice.

Open the builder →
Foundation Course · ~4.0 hrs

SDOH & the 30/60/90 Plan

SDOH screening (PRAPARE / AHC HRSN) + discharge framework + all five follow-up modalities, with CE alignment for Arizona, Indiana, and Pennsylvania.

Accreditation-ready
CHF Cluster · ~3.0 hrs

Heart Failure Transitions

Four-pillar GDMT, daily weights + green/yellow/red zone tool, RPM & community-paramedicine fit, and a red-flag escalation ladder.

Accreditation-ready
SCD Cluster · ~3.3 hrs

Sickle Cell Transitions

Pain, bias & the believing problem (NHLBI/ASH 60-min analgesia standard), hydroxyurea, infusion-center routing, pediatric→adult handoff. Doubles as DEI training.

Accreditation-ready

Next clones: COPD and Stroke/TIA. The foundation goes to the accreditation partner first, so their Nurse Planner can shape the cluster template before mass-cloning.

A stackable skill — not a certificate mill

The Care Transitions Specialist credential

Four completed builder cases stack into the Care Transitions Specialist micro-credential, sitting on the Prepared Provider ladder alongside our Ambassador and Caregiver tracks.

Aware→ Practitioner→ Specialist→ Lead→ Faculty
Every meaningful step pays out
LEARN It CoinLEARN It
LIVE It CoinLIVE It
SHARE It CoinSHARE It
For your team

Built for everyone who owns the arc home

Pitched differently for who's reading. Hospital buyers see budget lines; nurses see a credential; partners see a ready activity file.

Start here

🏥 Hospitals & CNOs

One asset funded from quality, workforce development, and health-equity budgets at once — with completion records you can put in front of a quality committee.

See the business case

🩺 Nurses & Care Teams

Build real 30/60/90-day plans, earn a stackable credential, and learn every follow-up modality — at your own pace, in plain language.

Try the builder

🎓 Accreditation Partners

Complete NCPD activity files — gaps, measurable objectives, evidence base, post-tests with rationales, contact-hour math — ready for your Nurse Planner's review.

Request the packet

💛 Foundation Donors

Fund a credentialed, equity-forward workforce that measurably keeps vulnerable patients out of the hospital. Your gift trains the people who do the work.

Learn more
The evidence base

Why this works — by the numbers

Every course carries full citations. A sample of the anchors the gap and intervention rest on:

42.5%

30-day readmission for inpatients with ≥1 PRAPARE-identified social need, vs 15% with none (PA academic medical center).

65%

lower 30-day readmission when medication needs were fully addressed in the Baltimore MIH community-paramedicine pilot.

~21%

reduction in 30-day all-cause readmissions with early outpatient follow-up across HF, COPD, MI & stroke (2024 meta-analysis).

HR 0.56

30-day readmission hazard with 4 vs 1 pillars of guideline-directed therapy at HF discharge (5-institution study).

34% vs 12%

30-day readmission for patients with sickle cell disease vs without, in a 140M+ hospitalization national cohort.

~1/3

of providers were aware NHLBI/ASH sickle-cell pain guidelines even exist — a measurable knowledge gap.

Try it — no sign-up

Build one care-transitions case in about 30 minutes

Walk the full loop a nurse walks: assess the patient, write measurable 30/60/90-day goals, route each window to the right person, pass the knowledge check, earn the case badge. See exactly what your team would experience.

▶ Launch the Care Transitions Builder

An honest note on accreditation

This program is built accreditation-ready — learning objectives, contact-hour design, post-tests with rationales, and evaluations are all in place. Awarding official CNE / nursing contact hours requires a partnership with an accredited provider or state nurses association whose Nurse Planner reviews and approves each activity. Until that partnership is signed, completion earns a Force for Health certificate. We never tell a CNO it's accredited before it is.

Welcome — +25 LEARN It Coins