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Clinical Operations · Quality Outcomes

Readmission Risk Agent

Scores 30-day readmission risk at discharge and triggers care management and follow-up protocols.

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The work it takes off your plate

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.

How it works

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.

  1. 1Score 30-Day Readmission Risk at DischargeEach discharging patient has a transparent 30-day risk score and driver list.
  2. 2Select Care Management and Follow-Up ProtocolsPatients are matched to the right post-discharge protocol intensity.
  3. 3Trigger Scheduling, Outreach, and HandoffsFollow-up and care management actions start without manual handoff gaps.
  4. 4Monitor Protocol Completion and Readmission OutcomesReadmission prevention workflows close the loop from risk score to measured outcome.

  1. Step 1: 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

    Result: Each discharging patient has a transparent 30-day risk score and driver list.

  2. Step 2: 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

    Result: Patients are matched to the right post-discharge protocol intensity.

  3. Step 3: 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

    Result: Follow-up and care management actions start without manual handoff gaps.

  4. Step 4: 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

    Result: Readmission prevention workflows close the loop from risk score to measured outcome.

Why use it

  • Actionable Risk. Scores arrive with protocols, not just numbers.
  • Fewer Preventable Readmissions. Triggers follow-up and care management at the right intensity.
  • Discharge Reliability. Reduces failed handoffs to ambulatory and post-acute teams.
  • SDOH Awareness. Incorporates social barriers into pathway selection.
  • Outcome Visibility. Ties protocol adherence to 30-day readmission results.