Post-Discharge TCM and Readmission Prevention

An ACO’s patients are discharged from many hospitals, each with its own transition process. The ACO often learns about the stay from an ADT feed or, weeks later, from claims. The first days at home are when medication questions, missed warning signs and unbooked visits show up.

Care coordinators already carry chronic care, quality gaps and wellness visits. Post-discharge calls compete with all of it, so the patients who looked stable at discharge are the ones who wait.

The care plan sets the steps and owners once. Agents run the outreach; your nurses take the clinical work.

The ADT message opens a care plan. Discharges from any connected hospital are matched to the attributed patient and ranked by readmission risk.

Outreach starts the same day. The agent calls or texts, confirms the patient is home, reviews the discharge instructions and collects the medication list.

Your nurse makes the TCM contact. Red-flag answers and medication discrepancies are escalated by rule. The interactive TCM contact and attestation stay with your clinical staff.

The follow-up visit is booked. ZynSchedule books the 7- or 14-day visit with the patient’s own primary care practice.

The episode closes when the visit is documented. Coordinators see who was reached, who was escalated and which visits are still open, by practice.

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.