Post-Discharge Outreach App

The Post-Discharge Outreach App closes the gap between hospital discharge and the first follow-up touchpoint. It automates patient check-ins through text, mobile, or portal notifications, collecting structured symptom responses and routing them directly to the right coordinator or nurse for review.

Patients receive short, conversational prompts that confirm medication understanding, wound status, pain levels, and appointment readiness. If concerning responses are detected, the app automatically flags them for escalation or initiates an outbound call request. This proactive approach enables early intervention before minor issues become readmissions.

Benefits

• Improved follow-up compliance: Keeps patients engaged and on schedule for post-discharge appointments and care plan tasks.
• Early issue detection: Surfaces symptom deterioration and medication issues before they escalate into readmissions.
• Reduced readmissions: Provides real-time visibility into patient status and ensures timely outreach by coordinators.
• Better patient experience: Simple, friendly, and secure, patients respond from their own device without needing a separate portal login.

Key Capabilities

• Automated mobile and web-based reminders tied to discharge date and diagnosis.
• Structured symptom and satisfaction surveys using FHIR Questionnaire and QuestionnaireResponse resources.
• Real-time escalation logic that routes alerts to care coordinators or on-call clinicians.
• Integration with EMR tasks, ADT updates, and case management systems for closed-loop follow-up tracking.
• Analytics dashboard for monitoring outreach completion, symptom trends, and unresolved escalations.

Great for

• Care Coordinators and Transition Teams: Automate patient follow-up after discharge with mobile check-ins, structured symptom surveys, and escalation alerts routed back to care teams.
• Quality Improvement and Population Health Leaders: Reduce readmission risk and improve continuity of care through proactive monitoring and response metrics.
• Clinical Informatics and EMR Analysts: Govern outreach logic, map survey responses to clinical data, and support longitudinal tracking with FHIR-based integration and escalation dashboards.
• Patient Experience and Engagement Teams: Deliver accessible, multilingual follow-up experiences that make patients feel connected and cared for after discharge.