Remember Becky.

Becky breaks a leg. The ER fixes it, she goes home.

Ten days later she is back, at a hospital down the street, but the first hospital gets the penalty.

Every model she passed through read her chart.

The chart ends at the parking lot.

Start with this week's discharges, this month's members. Person, address, the risk tier on file.

You get back a tier for every person, a plain-English reason with the source named, and the short list of people whose neighborhood disagrees with the chart.

Thirty days to deploy, no EHR integration, HIPAA-aligned on Google Cloud with a signed BAA.

If you run discharge planning at a hospital that pays readmission penalties, or member outreach at a Medicaid plan bracing for January 1, 2027, talk to Mike.