$15,200
Each preventable readmission costs $15,200
Award-Winning Patient Engagement Software
Core Capabilities of the AI Post-Discharge Follow-Up Agent
Multi-channel outreach, symptom monitoring, medication adherence, and EHR documentation.
Patient Outreach & Engagement
Automated outreach at 24h, 72h, 7, 14, and 30 days post-discharge by risk tier.
Symptom Monitoring & Escalation
Structured symptom checks for CHF, COPD, pneumonia, and post-surgical patients.
Medication Adherence & Reconciliation
Confirms prescriptions filled at 48h and 7 days, flagging adherence barriers.
Appointment & SDOH Navigation
Books or confirms PCP follow-up at the 24-hour post-discharge contact.
EHR Integration & Documentation
Logs every contact to Epic, Oracle Health, or athenahealth automatically.
Readmission & HRRP Analytics
Live dashboard segmenting patients by readmission risk and contact compliance.
Each Preventable Readmission Costs $15,200 — and 76% Are Preventable.
CMS enforces it with HRRP payment penalties of up to 3% of total Medicare reimbursement for hospitals with excess 30-day readmission rates.
Get Readmission Assessment
The Readmission Crisis Begins the Moment the Patient Leaves
Measured live in production deployments, not projected in a pitch deck.
30%
Reduction in 30-day readmission rates achieved by health systems implementing AI-driven…
100+
Enterprises running Bonami X AI in mission-critical healthcare operations.
24/7
Autonomous monitoring with real-time alerts across every workflow.
Our Process
Why Choose the AI Post-Discharge Agent
Drag or tap the dots to explore.
Automated Follow-Up Calls
24h to 30 days, readmissions cut 30%.
Early Symptom Escalation
Warning signs flagged days early.
HRRP Penalty Risk Cut
Prevention proven for CMS audits.
Works With Your Existing EHR and Patient Engagement Stack
The AI Post-Discharge Follow-Up Agent connects to leading EHR, patient communication, and post-acute care platforms.
Epic
Epic EHR FHIR R4 post-discharge readmission prevention integration
Oracle Health
Oracle Health Cerner EHR post-discharge patient monitoring integration
athenahealth
athenahealth EHR AI post-discharge follow-up automation integration
MyChart
MyChart portal post-discharge messaging and follow-up integration
Twilio
Twilio SMS and voice AI post-discharge patient outreach integration
PointClickCare
PointClickCare post-acute care AI discharge follow-up integration
Salesforce Health
Salesforce Health Cloud care management post-discharge integration
From the Desk of Our Esteemed Clients
Real results from enterprises that have deployed Bonami's AI solutions across industries.
Bonami's AI platform revolutionized our content creation process. Their natural language generation tools helped us scale our content production by 300% while maintaining exceptional quality and brand voice.
Stop Discovering Patient Deterioration at the Emergency Department Door
The warning signs that predict 76% of preventable readmissions are present in the days after discharge — in the patient's symptoms, medication adherence, and follow-up appointment compliance.
Book Prevention Demo
Core Capabilities of the AI Post-Discharge Follow-Up Agent
Multi-channel outreach, symptom monitoring, medication adherence, and EHR documentation.
01
Patient Outreach
Automated outreach at 24h, 72h, 7, 14, and 30 days post-discharge by risk tier.
02
Symptom Monitoring
Structured symptom checks for CHF, COPD, pneumonia, and post-surgical patients.
03
Medication Adherence
Confirms prescriptions filled at 48h and 7 days, flagging adherence barriers.
04
Appointment
Books or confirms PCP follow-up at the 24-hour post-discharge contact.
05
EHR Integration
Logs every contact to Epic, Oracle Health, or athenahealth automatically.
06
Readmission
Live dashboard segmenting patients by readmission risk and contact compliance.
Get in touch
Close the Post-Discharge Care Gap
Get a live demo of the Post-Discharge Follow-Up Agent and a 30-day readmission risk assessment.
Response within 24 hours
Your data is protected & secure
Free consultation, no obligation
Frequently Asked Questions
[ 1 ]
What is an AI Post-Discharge Follow-Up Agent?
It runs structured patient contact across the 30-day post-discharge window — symptom questionnaires, medication adherence checks, appointment confirmation, SDOH screening, and real-time escalation of warning signs.
[ 2 ]
How does symptom escalation work?
Thresholds are set by your clinical team per diagnosis. High-acuity signs — chest pain, severe breathlessness, stroke signs, suspected sepsis — trigger an immediate on-call alert; moderate cases route to a nurse with a 2–4 hour
[ 3 ]
How does the agent verify medication adherence?
At 48 hours it confirms prescriptions were collected and taken as directed, routing non-adherence to pharmacist follow-up. At 7 days a full adherence review also screens for reconciliation errors, using the discharge medication list pulled
[ 4 ]
What happens when patients do not respond?
Non-response is a clinical risk signal, not an administrative one. The agent makes at least three attempts per interval at different times of day; a missed 24- or 72-hour contact escalates to care coordination within 4 hours with attempt
[ 5 ]
How are social determinants of health handled?
SDOH screening runs at the 24-hour and 7-day contacts using a validated tool (AHC HRSN or PRAPARE), covering transport, medication access, food security, housing, and caregiver support.
[ 6 ]
Which EHRs and platforms does it integrate with?
Epic (FHIR R4, MyChart), Oracle Health/Cerner, athenahealth, NextGen, eClinicalWorks — any FHIR R4 endpoint. Outbound via Twilio voice/SMS, Amazon Connect, and MyChart secure messaging, with PointClickCare, MatrixCare, and Salesforce
[ 7 ]
How is HIPAA compliance maintained?
All PHI stays inside your HIPAA-compliant cloud environment under BAA coverage. Outbound messages carry minimal PHI — first name and general context, clinical detail kept in the secure portal — and every interaction and EHR write is
[ 8 ]
How long is implementation and what results follow?
Standard implementation runs 8–12 weeks: EHR and ADT integration, clinical protocol configuration, monitored pilot, then phased expansion. Health systems running structured AI follow-up typically see 20–35% reductions in 30-day
[ 9 ]
How is this different from generic patient outreach software?
Generic outreach broadcasts reminders on a fixed schedule with no clinical logic. This patient follow up software runs condition-specific symptom monitoring, medication verification, and SDOH screening at every interval, escalating warning
[ 10 ]
Can it calculate our HRRP penalty exposure?
Yes. It tracks 30-day readmission rates by CMS-measured condition against penalty thresholds and prior baselines on a live dashboard, and runs root cause analysis on each readmission — the evidence needed to quantify and reduce HRRP
[ 11 ]
Who builds and runs this agent?
This agent is one of 32 built and maintained by Bonami X AI, our production AI agent division. If you want an agent like this scoped for your own workflow, our AI agent development company team handles discovery, build, integration, and support end to end.
Global presence
