Transition of Care Agent
Manages handoffs from hospital to SNF, home health, or PCP with medication lists, goals, and follow-up tasks.
Hospital discharges fail when medication lists are incomplete, post-acute partners lack timely clinical packets, and PCP follow-up is not scheduled
Patients bounce back within 30 days when goals of care, equipment, and home support are not coordinated
Case managers juggle faxes, phone tags, and fragmented task lists across SNF, home health, and clinics
The Transition of Care Agent orchestrates handoffs with complete packets, med lists, goals, and follow-up accountability
The Transition of Care Agent activates on discharge planning milestones, assembles a best-possible medication list, packages clinical handoff content, and coordinates the receiving SNF, home health agency, or PCP. It creates follow-up tasks, tracks acceptance and first-visit completion, and escalates stalled transitions. Outcomes support reduced readmissions and cleaner continuity of care.
Activate on Discharge Readiness
- Detect anticipated discharge and disposition recommendations
- Identify receiving setting: SNF, home health, home with PCP, or other
- Collect barriers such as auth, transportation, and caregiver availability
Build Handoff Packet and Medication List
- Reconcile inpatient, home, and pharmacy medication sources
- Assemble diagnoses, hospital course, pending results, and goals of care
- Include DME, wound care, and follow-up appointment requirements
Coordinate Receiving Provider and Tasks
- Transmit packet to SNF, home health, or PCP with confirmation of receipt
- Schedule PCP or specialty follow-up within policy windows
- Assign accountability for med teaching, transport, and first visit
Track Completion and Escalate Risks
- Monitor start-of-care, SNF arrival, and follow-up appointment completion
- Escalate delayed handoffs and missed follow-ups to care management
- Capture readmission risk signals for post-discharge outreach