Use Case 1
Discharge Risk Stratification & Outreach
Trigger: ADT discharge event
1.Pull discharge summary and medication list
2.Score 30-day readmission risk with explainable drivers
3.Assign to tier-1/2/3 post-discharge protocol
4.Trigger outreach within protocol SLA
5.Schedule follow-up appointment
6.Monitor daily check-ins and symptom signals
✓
Every discharge gets the right level of post-discharge attention, automatically.
Use Case 2
Deterioration Escalation
Trigger: Patient check-in flags concerning signal (weight gain, missed meds, symptoms)
1.Classify signal severity
2.Page appropriate clinical role
3.Recommend specific intervention
4.Track time-to-response
5.Log outcome for model learning
✓
Deteriorating patients get clinical eyes within hours, not days.
Integrations
ADT Feed
EHR Discharge Summary
Pharmacy Claims
Remote Monitoring / Check-In Platform
Care Management System
Scheduling System
Industries
healthcare
See It In Action
A sample conversation with this agent
ADT discharge event just came in for James Patel, CHF.
Scoring now. James is 72, CHF exacerbation, 4-day stay, discharged on new furosemide dose plus metoprolol. 30-day readmission risk score: 0.68 (high). Drivers: prior CHF admission 8 months ago, new medication regimen, lives alone per SDOH screening. Triggering tier-1 post-discharge protocol: RN call within 24 hours, daily weight/symptom check-ins for 14 days, medication reconciliation within 48 hours, follow-up appt scheduled within 7 days. All scheduled and assigned.
James reported a 3-pound weight gain in 2 days on his check-in.
Escalating immediately. Weight gain >2 lbs in 48 hours is a decompensation signal in CHF. I've alerted his care manager and paged the on-call CHF nurse. Recommending: same-day telehealth visit, consider diuretic dose adjustment, review fluid and sodium intake. If unable to reach him by phone in the next 2 hours, escalate to home health visit or ED if symptomatic. Alert routed to his PCP as well.
Give me the 30-day outcomes for last month's discharges.
180 discharges last month, risk-stratified: 42 high-risk, 71 moderate, 67 low. 30-day readmission rate: 8.3% overall (vs. 14.1% baseline). High-risk tier: 16.7% readmit rate (vs. 28% historical). Moderate tier: 5.6%. Low: 1.5%. Estimated avoided cost: $340K. Top root causes of the readmissions that did occur: medication adherence (5), missed follow-up (3), new infection (3), underlying disease progression (4).