Every Patient
Every discharged patient should get a timely check-in. In practice coordinators call the highest-risk cases and hope the rest do not deteriorate quietly at home during the window when readmissions are decided.
Post-Discharge Agent: Follow-Up and Triage
One agent runs the check-in, triages warning signs, books follow-up, and escalates urgent cases.
Scope a Post-Discharge AgentAbout the Agent
Post-discharge follow-up, triage, scheduling, and EHR notes in one agent workflow.
Category
Transition of Care / Readmission Reduction Agent
Post-discharge check-ins, symptom screening, follow-up booking, and escalation.
Autonomy Level
Four Steps, One Agent
Communication, triage logic, scheduling, and documentation run as one sequence — not four handoffs.
How It Works
Check In, Screen, Book, Escalate
Reaches the patient on schedule, screens the response, books follow-up, and routes urgent cases to staff.
Integration
FHIR R4, Scheduling, Portal & SMS
Reads the discharge summary, writes the interaction back to the chart, and reaches patients where they are.
The Boundary
Screening Is Not Diagnosis
The agent flags warning signs against defined criteria; deciding whether a patient needs emergency care stays with a clinician.
Build your idea
Talk to our experts
Scope a post-discharge agent against your own discharge volume and escalation protocols.
The Problem It Solves
Follow-up calls are the first thing dropped when the unit is busy.
Four Handoffs
A single follow-up spans four jobs — reach the patient, interpret the answer, decide whether it warrants a visit, and get it on a calendar. Split across systems and people, steps get dropped.
Direct Cost
Readmission reduction is one of the few healthcare AI use cases with an unambiguous financial line — avoided admissions and avoided penalties both land on the same ledger.
Every discharged patient
checked in on — not just
the ones staff could call
Talk to Our Team
How the Agent Works
-
Scheduled Post-Discharge Check-In
Scheduled Post-Discharge Check-In
- Reads the discharge summary to set cadence and questions
- Reaches the patient by portal or SMS, and follows up
- Covers the full discharge cohort, not a subset
-
Warning-Sign Screening
Warning-Sign Screening
- Screens answers against clinical warning criteria
- Separates normal recovery from deterioration signals
- Records the result and rationale in the chart
-
Follow-Up Scheduling
Follow-Up Scheduling
- Books the follow-up visit through the scheduling API
- Matches clinician, site, and urgency window
- Confirms, reminds, and rebooks without a coordinator
-
Urgent Escalation to Clinical Staff
Urgent Escalation to Clinical Staff
- Routes urgent responses to clinical staff at once
- One escalation queue with answers and discharge context
- Flags unclear responses for human review
-
Readmission Reporting
Readmission Reporting
- Tracks contact, escalation, and 30-day readmission rates
- Compares screened cohorts to the pre-agent baseline
- Shows which conditions need a tighter cadence
Why Build It With Bonami
We build the parts that survive clinical review: triage, escalation, audit trail, EHR integration.
Clinician-Authored Triage Logic
Criteria and thresholds authored with your clinicians, versioned and reviewable.
Discharge-to-Chart Integration
Reads the discharge summary over FHIR and documents back to the chart.
Escalation Designed, Not Assumed
Where urgent responses land, who owns them, and what happens out of hours.
Full Action-Level Audit Trail
Every message, decision, booking, and escalation logged with its rationale.
What Deployments Report
Every number below was measured in production after launch — not projected in a pitch deck.
4-in-1
Steps in One Agent — Communication, triage, scheduling, notes
Full
Discharge Cohort Covered — Not just the highest-risk subset
Readmits
Clearest AI Financial Case — Avoided admissions and penalties
2026
Live in Health Systems Today — A leading agentic use case, not a pilot
Global presence
