With Insights, teams can see:
🏥 Prevented hospitalizations
🚑 Hospital transfer outs with automated root-cause analysis
📊 Drill down graphs for pattern recognition
📉 Readmission Rates over time
Modules Within Insights
1. Prevented
Highlights patients in whom Circadia flagged early changes, and timely intervention helped avoid hospital readmissions.
Create Summary
For any patient, select Create Summary to generate a detailed case study.
The summary may include:
Conditions preceding the escalation (what changed prior to the flag)
Acknowledgement details (how quickly the flag was acknowledged)
Interventions post escalation (orders/actions taken after the flag)
Transfer prevented status (Yes/No)
Transfer prevented justification (why this event is considered prevented)
These case studies can be repurposed into tangible collateral that supports two key initiatives:
Hospital Case Manager Marketing: Clear, real-world examples that help hospital case managers see how your team enables earlier intervention, smoother transitions of care, and more predictable post-acute outcomes; reinforcing repeat referral decisions due to improved patient outcomes.
Staff Teach-Back: Case studies that enable nursing staff to reinforce learning, validate understanding, and consistently apply Circadia insights in daily workflows.
2. Discharged
View real-time data for patients discharged from the SNF. Some discharges may represent potentially preventable readmissions or transfers, helping your team identify opportunities to improve care and transitions.
Create Summary
Click on Create Summary next to any patient to open a detailed Root Cause Analysis (RCA) report for that discharge.
The summary includes:
Conditions leading to escalation
Circadia Flags triggered and acknowledgement timing
Interventions taken by the care team
Clinical timeline and context
Outcome details (transfer/discharge reason)
Recommended preventative actions
PCC transfer-out reason
3. Transfers
These cases show patients who were transferred from the SNF to acute care. Reviewing these events can help identify opportunities for improvement and reduce avoidable rehospitalizations.
Use the Trend dropdown filters to analyze patterns across transfers and uncover system-level insights — not just individual cases.
Trend Filters Explained
Trend – View overall transfer volume and changes by month.
Payer Type – Compare transfers across insurance groups.
Time of Day – Identify when transfers most frequently occur during the day.
Day of Week – Spot patterns tied to specific weekdays or weekends.
Transfer Reason – Analyze the patient conditions or clinical causes driving transfers.
Primary Physician – See transfer trends by the patient’s assigned physician.
Ordering Physician – Review transfers based on the provider who initiated care or orders.
Two summary panels:
All-cause – all transfers to acute care
Preventable – transfers identified as potentially avoidable, as deemed by CMS guidelines
Create Summary
Click Create Summary next to any patient to generate a detailed Root Cause Analysis (RCA) for that transfer.
The summary provides a clear timeline of what happened before the transfer, including:
Conditions leading to escalation
Circadia Flags triggered and acknowledgement timing
Clinical observations and trends
Interventions or orders placed
Recommended preventative actions
PCC transfer-out reason
This helps your team quickly understand why the transfer occurred and where earlier intervention may have been possible.
4. Outcomes
The tab tracks key outcome metrics across facilities over time, including readmissions, hospitalizations, and transfer-out events, helping your team measure performance and the impact of proactive care.
The Outcomes tab consists of
Date range filters
Metric selection (e.g., 30-day readmissions)
Metric type (normalized/raw)
Patient type filters
Monthly trend charts
Summary metrics with current vs. prior period comparisons
How to use
Monitor outcome trends month-over-month
Measure reductions in avoidable events
Track program effectiveness
Support QAPI and leadership reporting
Share performance insights with stakeholders
Leveraging Circadia Insights
Quality Improvement – Use objective data to support QAPI reviews.
Root Cause Analysis – Connect Circadia Flags to outcomes to quickly understand what happened and why.
Financial & Referral Impact – Demonstrate reductions in readmissions and hospital transfers to support ROI, value-based care programs, and stronger hospital referral confidence.
Clinical & Operational Leadership – Provide administrators and medical directors with clear visibility into trends, staff response times, and patient outcomes.
Actionable Trends – Identify recurring patterns to target workflow gaps and drive continuous improvement in the care process.
With the Insights tab, leadership can clearly see where Circadia made a measurable impact — from preventing transfers to improved outcomes over time.
💬 Need Help?
Our team is here to support you. Use the chat feature in the CIP app, or email [email protected].