Customer story
Space Coast ACO, an MSSP ACO serving Medicare beneficiaries in Brevard County, Florida, uses Zynix outreach agents and readmission risk analytics for follow-up after discharge.
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Segment
ACO
Program
Medicare Shared Savings Program
Region
Brevard County, Florida
Workflows
Post-discharge follow-up, patient callbacks
The challenge
For transitional care management, CMS expects an interactive contact within 2 business days of discharge. Manual outreach reached too few of Space Coast ACO’s discharged patients inside that window, so the ACO could not bill TCM for many discharges, and patients without follow-up were more likely to return to the emergency department.
TCM timing: CMS, Transitional Care Management Services.
Workflows
Outreach after every discharge, ranked by readmission risk, with clinical staff keeping every clinical conversation.
Agent
Contacts each discharged patient, checks that a follow-up visit is booked and notes barriers such as transportation.
Clinical staff
Clinical staff make the TCM interactive contact and handle medication questions.
Zynix
Ranks recent discharges by readmission risk.
Clinical staff
The care team calls the highest-risk patients first.
Agent
Answers patients calling back after discharge and captures the reason for the call.
Clinical staff
Clinical questions go to the care team by rule.
Care management Demo Example episode · sample data
Post-discharge episode
Pt 1042 · 72 · CHF
Day 0
Discharge notice received from the hospital
System
Logged
Day 0
Outreach call placed; patient reached
Outreach agent
Reached
Day 1
Follow-up visit booked for day 6
Outreach agent
Booked
Day 1
Medication question routed to the care team
Outreach agent
Escalated
Day 1
TCM interactive contact
Care manager, RN
Completed
Day 6
Face-to-face visit
Physician lead
Queued
The agent makes the calls and books the visit. The RN owns the clinical contact.
Illustration of the workflow with sample data. Not Space Coast ACO patient data.
Before and after
What changed at Space Coast ACO
Workflow
Before
With Zynix
Post-discharge contact
Manual calls reached too few patients inside the window.
Every discharge gets an outreach attempt; exceptions route to the care team.
Prioritization
Worked in discharge order.
Ranked by readmission risk.
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Built for
ACOs TCM, AWVs, HCC and quality gaps →
Products
Care plans TCM, AWV and CCM workflows →
All AI agents How agents work with your care team →
We’ll show the workflows Space Coast ACO uses, on sample data, and what it would take to run them in your organization.