Discharge follow-up lags, and the return comes out of your shared savings.
Gia calls every patient after discharge and tells your team who needs a visit first.
- 30 daysthe return window you own
- 2027LEAD begins for Original Medicare ACOs
- < 2 minresults to the transitions team
- 5 of 5pre-registered outcomes passed
Three episodes you pay for. Each starts at home, between visits.
A hip fracture you own for thirty days.
Since January 2026, TEAM puts the surgical episode on the hospital's book. The fall came first.
A return to hospital inside the window.
The readmission penalty lands on the hospital. The lost shared savings land on you.
Dementia care becomes a line item in January 2027.
LEAD makes dementia care a line item. Memory problems go unnoticed for years.
Hospitals are penalized for the readmission, not the fall. The fall is the first sign anyone could have acted on.
Day one at home, a call. Day two, a shorter list.
Gia calls on the first day home.
Phone or video, in the patient's language, forty seconds. A missed call is retried.
Your transitions team sees who is slipping.
A ranked worklist with reasons. Proactive Decision Actions beside each name: options, never orders.
Epic has it before the next huddle.
Results, notes and follow-up write back to Epic or your EHR. The loop closes in the record.
Gia is a Digital Human® with Voice AI. Every result is an option for a clinician to review, not a diagnosis.
The loop after discharge, closed in the record.
Post-discharge calls
Every patient, every day you choose, with no one on your staff dialing.
Ranked worklist
Who to visit first, and why. Reviewed by a clinician before anything moves.
Initiate Assessment
Cognitive screening, BIMS, ADL and IADL on demand, results in under two minutes.
Follow-up record
What was chosen, by whom, and what happened next.
Caregiver check-ins
The family's report of the week reaches the chart, not a voicemail.
Gia Health Analytics
Run the model on your attributed population. Google Cloud Marketplace and AWS Marketplace.
- M.R.81HighTwo new sedatives
- J.T.77HighRecent ER visit
- A.L.84ElevatedWeight drifting down
- D.K.79ElevatedGait change noted
- S.P.72WatchMissed two calls
Options for review. A clinician decides.
The worklist starts from each patient's history, read by Scienza's own foundation model for aging. Sealed test on 469,000 people; five outcomes passed, falls replicated, hospital return trained. About the model.
Close the loop before the window closes.
Twenty minutes. Your discharge list, your Epic, your attributed population.
Questions
Does Gia tell us which patients will come back to the hospital?
The hospital-return head is trained and available now in Gia Health Analytics. In the care platform, Gia's job is the call after discharge and the follow-up record. A clinician decides who gets a visit.
What changes with LEAD?
From January 1, 2027, the CMS LEAD model makes dementia care a line item for Original Medicare ACOs. Gia gives your team a ranked list of who to assess and writes the assessment to the record.
Where does the data live?
Gia Health Analytics is hosted by Scienza, with on-premises deployment coming soon. Care-platform results write back to Epic, PointClickCare or your EHR under HIPAA.
Does Gia replace the transitions nurse?
No. Gia places the calls and listens. The nurse gets a shorter list and the reasons, and makes the call on what happens next.