The Transitions of Care Agent reaches every discharged patient within 48 hours, catches medication issues before they become adverse events, and captures TCM billing documentation before the window closes.
The 30-day window after discharge is when intervention is cheapest and contact is hardest to guarantee. The agent manages the full post-discharge sequence.
Contacts the patient within 48 hours of discharge to review medications, identify confusion or access barriers, and flag issues for clinical review before they become adverse events.
Books the follow-up visit within the TCM window — 7-day or 14-day — through ZynSchedule. The visit is confirmed, not just attempted.
Captures the documentation required for TCM billing — contact attempt, medication review, follow-up confirmation — so the billing window does not expire because paperwork was incomplete.
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