Transitions

Care transitions management software for timely, compassionate end-of-life planning

Give your teams the insights they need to align clinical services and move patients into the right care setting.

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Predictive alerts
Hospice eligibility identification
Near real-time coordination
Risk stratification

Nurse places blanket on elderly patient in wheelchair

Guide every patient to the right care

Too often, patients miss timely hospice care because decline patterns go unnoticed. Mosai Transitions uses predictive analytics to flag at-risk patients early, giving your teams the insights they need to move patients into the ideal care settings with confidence.

Support every transition with confidence and compassion

Identify decline early

Get AI-driven insights when patients show signs of nearing end of life – so you can give them the care and comfort they deserve.

Coordinate with ease

Keep teams aligned with shared dashboards, in-platform notes, clear workflows, and instant communication tools.

Improve care outcomes

Move patients into hospice at the right time – reducing hospitalizations and improving quality scores.

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Key features

Combining AI-driven care analytics with near real-time clinical insights, Mosai Transitions helps you anticipate patient needs, optimize resources, and deliver compassionate end-of-life care.

Transitions - Risk-based patient ranking

Patient-level analytics

Use clinical data and industry benchmarks to identify patients who are likely to require hospice care in the next 60 days.

Custom transition workflows

Keep your team on track with configurable transition stages, built-in follow-ups, and clear accountability at every step.

Outcome recommendations

Get data-backed guidance to support discharge planning and hospice care transitions.

Performance dashboards

Monitor live quality indicators, transition metrics, utilization, and team performance to ensure smoother handoffs and better outcomes.

Predictive alerts

Receive automated notifications when patient conditions change, so you can intervene proactively and reduce late or unnecessary transitions.

Clearer data, smarter decisions, better care

52% reduction in deaths on home health census

50% increase in billable hospice days

47% more visits in the last week of life

With Mosai Transitions, our teams have clarity and confidence when guiding patients into hospice. It’s data that supports compassion.

Lindsey Wilson, VP of Clinical Excellence VitalCaring

Compliance you can count on

Our care transitions management software keeps patient data safe through HIPAA compliance and adherence to HITRUST standards – so you can focus on care, not compliance.

FAQs

Predictive analytics for transitions helps home health teams identify patients who may be nearing end of life. By analyzing clinical data on a visit-by-visit basis and comparing it against industry benchmarks, the software flags high-risk patients. This helps clinicians prioritize care, plan timely hospice referrals, and reduce late or unnecessary hospitalizations.
Care transitions software helps healthcare teams manage patients moving between care settings, such as from home health to hospice. It provides risk stratification tools, near real-time insights, shared dashboards, and workflow tools to improve coordination, ensure timely care, and help clinicians make data-driven decisions for each patient.

Care transitions management software for timely, compassionate end-of-life planning

Predictive alerts

Hospice eligibility identification

Near real-time coordination

Risk stratification

Guide every patient to the right care