Hospital Discharge & Transitions of Care
A patient is discharged after a cardiac event. Automated care pathways ensure follow-ups, medication adherence, and early warning if the patient disengages.
Microsoft Teams
Care Coordination — Discharge ChannelDischarge Pathway ActivatedAuto-triggered
Patient: William J., 68
Diagnosis: CHF Exacerbation
Discharged: Apr 12, 2026
PCP: Dr. Rivera
Pathway created: 7-day intensive → 30-day monitoring → PCP handoff
Google Calendar
Post-Discharge Schedule — William J.Day 1Medication check-in (SMS)
Day 2Wellness check — how are you feeling?
Day 3Follow-up with Cardiology
Day 7PCP Follow-up — Dr. Rivera
Day 14Lab work — BNP levels
Day 30Transition to routine monitoring
Microsoft Teams
Alert — Patient Not EngagingEngagement AlertAI Alert
William J. has not responded to the last 2 check-ins (Day 4, Day 5). Medication adherence unconfirmed.
Suggested Actions:
- Phone call from care coordinator
- Escalate to PCP if no response by Day 6
- Notify family contact on file
AI Suggested
Before
- Discharge instructions given on paper, often lost
- Follow-up scheduling left to the patient
- No visibility into post-discharge medication adherence
- Readmission discovered only when the patient returns to the ED
After
- Discharge triggers an automated care pathway instantly
- Follow-up appointments pre-scheduled and confirmed via SMS
- Daily medication and wellness check-ins for the first 30 days
- Care team alerted immediately if the patient doesn't engage
"Readmissions are preventable when you close the gap between discharge and follow-up — using the same tools your team already works in."
Key Takeaway
Outcomes Acceptance Testing
PatientTeam tests every workflow outcome. Our colleagues work with your teams to define acceptance criteria and verify that each scenario delivers the results patients and staff depend on.