Post-Discharge Follow-Up for High-Risk FQHC Patients

Health center patients are discharged from hospitals across the region, often with instructions in a language they don’t read and a follow-up visit they can’t get to. Without an ADT feed, the center hears about the stay when the patient calls, or when claims arrive.

Standard follow-up assumes the patient reads English, answers the phone during business hours and can arrange a ride. For many health center patients, one of those is missing.

Agents reach the patient and book the visit. Your care team handles the clinical questions and the barriers.

The discharge reaches your health center. ADT messages from connected hospitals are matched to your patient the same day.

Outreach in the patient’s preferred language. The agent confirms the patient is home, goes through the discharge instructions and asks about medications and getting to the follow-up visit.

Clinical questions go to your nurses. Symptoms and medication questions are escalated by rule, with the conversation attached. The TCM contact stays with your clinical staff.

Barriers go to a coordinator. A patient who reports no ride, no refill or no reliable phone is routed to a coordinator or community health worker.

The follow-up visit is booked. ZynSchedule books the visit at the health center, and reminders go out before it.

Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.