Automated Follow-Up Calls
24h to 30 days, readmissions cut 30%.
Award-Winning AI Development & Consulting
Clinical & Front-Office
The Readmission Crisis Begins the Moment the Patient Leaves
Harvard Medical School estimates 76% of 30-day hospital readmissions are potentially preventable — driven not by illness severity but by the breakdown in care continuity that occurs in the hours and days following discharge.
Read the full evidence
CMS HRRP imposes penalties of up to 3% of total Medicare reimbursement on hospitals with excess readmission rates. The Commonwealth Fund places the total US annual cost of avoidable readmissions at $26 billion, averaging $15,200 per preventable event. Yet only 30–40% of patients receive any follow-up contact within 7 days of discharge (Advisory Board); 43% cannot recall discharge instructions within 24 hours (JAMA); and 50% do not take their discharge medications as prescribed (Journal of General Internal Medicine).
$15,200 The Commonwealth Fund places the total US cost of avoidable readmissions at $26 billion annually. The AI Post-Discharge Follow-Up Agent addresses the documented root causes of preventable readmission — medication non-adherence, missed follow-up appointments, undetected symptom deterioration, and SDOH barriers — through evidence-based automated outreach at 24 hours, 72 hours, 7 days, 14 days, and 30 days post-discharge. Book a readmission risk assessment to calculate your organisation's HRRP penalty exposure.
Business impact
30%
reduction in 30-day readmission rates achieved by health systems implementing AI-driven post-discharge follow-up with structured symptom escalation protocols — versus standard discharge processes with no systematic outreach
- $15,200
- CMS enforces it with HRRP payment penalties of up to 3% of total Medicare reimbursement for hospitals with excess 30-day readmission rates.
Core Capabilities of the AI Post-Discharge Follow-Up Agent
Multi-channel outreach, symptom monitoring, medication adherence, and EHR documentation.
01
Patient Outreach & Engagement
Automated outreach at 24h, 72h, 7, 14, and 30 days post-discharge by risk tier.
02
Symptom Monitoring & Escalation
Structured symptom checks for CHF, COPD, pneumonia, and post-surgical patients.
03
Medication Adherence & Reconciliation
Confirms prescriptions filled at 48h and 7 days, flagging adherence barriers.
04
Appointment & SDOH Navigation
Books or confirms PCP follow-up at the 24-hour post-discharge contact.
05
EHR Integration & Documentation
Logs every contact to Epic, Oracle Health, or athenahealth automatically.
06
Readmission & HRRP Analytics
Live dashboard segmenting patients by readmission risk and contact compliance.
Why Choose the AI Post-Discharge Agent
Early Symptom Escalation
Warning signs flagged days early.
HRRP Penalty Risk Cut
Prevention proven for CMS audits.
Integrations
Works With Your Existing EHR and Patient Engagement Stack
The AI Post-Discharge Follow-Up Agent connects to leading EHR, patient communication, and post-acute care platforms.
7 named systems it connects to
Also connects to PointClickCare
Running something not listed here? Tell us on the call — scoping the connector is the first step.
AI Post-Discharge Follow-Up Agent
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Epic
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Oracle Health
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athenahealth
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MyChart
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Twilio
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Salesforce Health
Related Case Study
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AI Post-Discharge Follow-Up Agent — FAQs
[ 1 ]
What is an AI Post-Discharge Follow-Up Agent?
It runs structured patient contact across the 30-day post-discharge window — symptom questionnaires, medication adherence checks, appointment confirmation, SDOH screening, and real-time escalation of warning signs. It covers the five CMS HRRP conditions plus post-surgical, oncology, and SNF-to-community transitions.
[ 2 ]
How does symptom escalation work?
Thresholds are set by your clinical team per diagnosis. High-acuity signs — chest pain, severe breathlessness, stroke signs, suspected sepsis — trigger an immediate on-call alert; moderate cases route to a nurse with a 2–4 hour callback, low-acuity concerns become a follow-up task.
[ 3 ]
How does the agent verify medication adherence?
At 48 hours it confirms prescriptions were collected and taken as directed, routing non-adherence to pharmacist follow-up. At 7 days a full adherence review also screens for reconciliation errors, using the discharge medication list pulled from the EHR via FHIR R4.
[ 4 ]
What happens when patients do not respond?
Non-response is a clinical risk signal, not an administrative one. The agent makes at least three attempts per interval at different times of day; a missed 24- or 72-hour contact escalates to care coordination within 4 hours with attempt history and risk score attached.
[ 5 ]
How are social determinants of health handled?
SDOH screening runs at the 24-hour and 7-day contacts using a validated tool (AHC HRSN or PRAPARE), covering transport, medication access, food security, housing, and caregiver support. Positive screens route to the right program and are documented in the EHR.
[ 6 ]
Which EHRs and platforms does it integrate with?
Epic (FHIR R4, MyChart), Oracle Health/Cerner, athenahealth, NextGen, eClinicalWorks — any FHIR R4 endpoint. Outbound via Twilio voice/SMS, Amazon Connect, and MyChart secure messaging, with PointClickCare, MatrixCare, and Salesforce Health Cloud connectors.
[ 7 ]
How is HIPAA compliance maintained?
All PHI stays inside your HIPAA-compliant cloud environment under BAA coverage. Outbound messages carry minimal PHI — first name and general context, clinical detail kept in the secure portal — and every interaction and EHR write is logged to an immutable audit trail.
[ 8 ]
How long is implementation and what results follow?
Standard implementation runs 8–12 weeks: EHR and ADT integration, clinical protocol configuration, monitored pilot, then phased expansion. Health systems running structured AI follow-up typically see 20–35% reductions in 30-day readmissions within 6–12 months.
[ 9 ]
How is this different from generic patient outreach software?
Generic outreach broadcasts reminders on a fixed schedule with no clinical logic. This patient follow up software runs condition-specific symptom monitoring, medication verification, and SDOH screening at every interval, escalating warning signs to the care team in real time.
[ 10 ]
Can it calculate our HRRP penalty exposure?
Yes. It tracks 30-day readmission rates by CMS-measured condition against penalty thresholds and prior baselines on a live dashboard, and runs root cause analysis on each readmission — the evidence needed to quantify and reduce HRRP penalty risk.
Each Preventable Readmission Costs $15,200 — and 76% Are Preventable.
The warning signs that predict 76% of preventable readmissions are present in the days after discharge — in the patient's symptoms, medication adherence, and follow-up appointment compliance. Get a live demo of the Post-Discharge Follow-Up Agent running against your patient population and a 30-day readmission risk assessment for your current discharge volume.
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