Readmission Risk Agent
Scores 30-day readmission risk at discharge and triggers care management and follow-up protocols.
Many preventable 30-day readmissions stem from missed follow-up, medication confusion, and unaddressed social risk that are not acted on at discharge
Risk scores arrive too late or without clear next steps for care managers
High-risk patients leave without scheduled appointments or home support
The Readmission Risk Agent scores risk at discharge and automatically triggers care management and follow-up protocols matched to patient need
At discharge planning and final disposition, the agent computes 30-day readmission risk from clinical, utilization, medication, and social features; assigns protocol pathways; and launches follow-up scheduling, pharmacy reconciliation support, and care management outreach with tracked completion.
Score 30-Day Readmission Risk at Discharge
- Combine diagnoses, prior utilization, length of stay, vitals trends, and polypharmacy signals
- Incorporate SDOH, payer, and post-acute disposition factors
- Generate an interpretable risk score with top contributing drivers
Select Care Management and Follow-Up Protocols
- Map risk tiers and conditions to protocol bundles such as HF, COPD, or general high risk
- Determine required follow-up windows, telemonitoring, and pharmacy touchpoints
- Identify barriers such as no PCP, transportation, or language needs
Trigger Scheduling, Outreach, and Handoffs
- Create follow-up appointment requests and care manager tasks before discharge when possible
- Alert outpatient clinics, home health, and pharmacy teams of high-risk discharges
- Deliver patient-friendly discharge checklists and medication teach-back prompts
Monitor Protocol Completion and Readmission Outcomes
- Track completed follow-ups, outreach attempts, and medication reconciliation within target windows
- Flag patients who miss first follow-up for rapid re-engagement
- Report 30-day outcomes and protocol effectiveness by service line