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