Transition of Care Agent

The work it takes off your plate

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.

How it works

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.

1. Step 1: 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

   Result: Each discharging patient has a structured transition plan skeleton.

2. Step 2: 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

   Result: A complete handoff packet is ready for the receiving care setting.

3. Step 3: 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

   Result: Receiving teams accept the patient with clear tasks and timelines.

4. Step 4: 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

   Result: Transitions close the loop with measurable completion and escalation.

Why use it

• Reduces readmissions by ensuring complete, timely post-acute handoffs. Standardizes medication reconciliation and goals-of-care transfer. Gives case managers visibility from discharge decision through first follow-up. Improves partner performance with tracked acceptance and start-of-care SLAs.