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Data Tools | Baltimore Health Analytics

BHA’s Rover-Transitions

A system to manage the work health plans do to improve the NCQA® HEDIS® Transitions of Care measure and CMS Star Ratings.

Tracking inpatient hospital transition to home.

Evaluate the patient’s medication utilization when they leave the hospital.

Our Assumptions

Hospital discharges are complicated and can be confusing for the patient.

Medicare and Medicaid place increased emphasis on reducing 30-day readmissions, along with measuring the coordination between providers, especially:

  • Communication of admissions and discharge plans.
  • Track all the activity around hospitalizations: discharge summary, medication review, patient engagement, notifications and communication upon discharge.

What are we solving?

  • Tracking of data around an inpatient hospital transition to home.
  • Emphasis on decreasing patient readmission by facilitating communication between patient and PCP.
  • Monitoring reconciliation of pre-hospitalization medications and changes made during the hospital stay.


  • Enables user to track patient transitions from inpatient care to home.
  • Allows user to verify clinician review/reconciliation of patient medication.
  • Easily document phone calls, follow up visits and chart notes.
  • Effortlessly view:
    • Patient admission and discharge data.
    • Detailed patient information.
    • PCP/Doctor information.
  • Display data to allow easy contact with patient or patient family.
  • Quick storage and retrieval of all finding and data.