For clinicians
Fireline Care Transitions. The post‑discharge worklist your team will actually open.
Risk‑sorted patients in their 30‑day window, SDOH referrals with closed‑loop tracking, caregiver SMS, TCM and CCM billing surfaced when criteria are met. One panel. No second EHR.
The right patient, first.
Risk‑sorted by condition, prior utilization, and active SDOH flags. No reading down a 60‑row spreadsheet.
SDOH that actually closes.
Referrals to food, transport, housing, behavioral health, with status pills, not hopeful faxes. Education flags route to clinician literature at the next visit.
Billing without the audit dread.
TCM / CCM eligibility surfaced as it accrues. The chart documents itself as the team works.
Not yet a partner site?
Fireline Care Transitions is rolled out clinic by clinic, with the LMSW lead on our side configuring it to your workflow before anyone logs in.
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