Discharge Planning Agent
Coordinates discharge readiness, post-acute placement, and follow-up appointments to shorten length of stay and reduce readmissions.
Discharge delays often stem from late identification of post-acute needs, incomplete medication reconciliation, and fragmented communication among case management, therapy, and physicians
Finding SNF, home health, or DME availability can take days, extending avoidable inpatient days
Patients leave without timely PCP or specialty follow-up, driving preventable 30-day readmissions
Manual tracking of barriers across units creates inconsistent readiness assessments and last-minute scrambles on the day of discharge
The Discharge Planning Agent evaluates clinical readiness, social determinants, payer authorization status, and post-acute capacity to build a living discharge plan from admission forward. It sequences tasks for case managers, therapy, pharmacy, and scheduling while monitoring barriers that threaten the target discharge date. Automated placement outreach and follow-up booking close the loop so patients transition safely with fewer avoidable days.
Assess Discharge Readiness Early
- Score medical stability, functional status, and caregiver support
- Identify likely disposition (home, HH, SNF, IRF, hospice)
- Set a target discharge date with barrier risk flags
Coordinate Tasks and Clear Barriers
- Assign med rec, teaching, therapy clearance, and authorization tasks
- Track DME, transportation, and prior auth completion
- Escalate overdue tasks to charge nurse or case management lead
Secure Post-Acute Placement and Follow-Up
- Match patients to post-acute providers by clinical need, payer, and bed availability
- Package clinical packets for receiving facilities
- Book PCP and specialty follow-ups within recommended windows
Confirm Safe Transition and Readmission Safeguards
- Verify after-visit summary, meds, and red-flag education
- Trigger high-risk readmission outreach protocols
- Capture LOS and readmission outcomes for continuous improvement