ED discharge follow-up
Reach every patient after an ER visit.
Clara, the AI care agent from Pythagoras AI, connects to ADT feeds and calls patients after an ER visit. She checks on symptoms and medicines and books a visit with their doctor. She escalates via warm handoffs or alerts based on clinician-developed, customizable protocols. Fully managed by Pythagoras AI.
We manage Clara. Your team stays in charge.
After an ER visit
Clara gets the patient back to their own doctor after an ER visit.
In this sample call, the patient went to the ER for a bad cough and didn't know they had a regular doctor.
Clara
After your ER visit
“The ER asked you to see your doctor this week. Would you like me to book that?”
“I didn't know I had a doctor. I usually just go to the ER.”
Team alert
Primary care team
What the caller said
“I didn't know I had a doctor. I usually just go to the ER.”
- Doctor
- Clara told the patient who their doctor is
- Follow-up visit
- Booked for Thursday at 10:00 AM
- After hours
- Patient has the nurse line number
Send to Primary care team
Review the call summary and mark it reviewed.
The problem
Patients go back to the ER for problems their own doctor could handle.
Most ER patients go home the same day with a note to see their own doctor. When that visit doesn't happen, many of them end up back in the ER.
They use the ER as their doctor
Some patients don't have a regular doctor, or can't get through to the office, so they go to the ER for most problems.
What Clara does: Confirms who their doctor is and books a visit there. If they don't have one, she lets your team know so they can set one up.
They don't book the visit the ER told them to make
The discharge sheet says to see their doctor in a few days. The patient means to call but never does.
What Clara does: Books the visit with their doctor during the call.
They don't know who to call at night or on weekends
When something feels wrong after hours, the ER is the only number they know.
What Clara does: Gives them the number to call next time and answers inbound calls 24/7, with a warm handoff to a nurse when it's urgent.
Your team finds out days later
The ER visit reaches your team late. By then the patient is hard to reach or already back in the ER.
What Clara does: Connects to your ADT feed and calls the patient soon after they leave the ER.
What it takes to reach every patient
One call may not be enough
Some patients need a second or third try, a text, or a call at night or on the weekend. Clara can make outbound calls and handle inbound calls 24/7.
Patients may not pick up
An unknown number can put patients off. Pythagoras AI manages texting and branded calling.
Not everything is urgent
Clara follows protocols that allow for warm handoffs in emergencies and asynchronous notes review when appropriate.
How it works
What we do.
- 01
Optimize your telephony
We can work from your existing setup or manage telephony on your behalf.
- 02
Connect to your systems
Connect to your ADT feeds, EHR and care management software.
- 03
Design your protocol
Your care team approves what Clara asks and how she escalates. Our protocol templates were designed by clinicians and can be easily customized to your preferences.
- 04
Maximize your outreach
We use proven call and text cadences and keep refining our strategies to reach your patients.
- 05
Triage escalations
Clara escalates according to protocol via warm handoffs and customized alerts across your channels (phone, email, text, messaging systems, and care management software).
- 06
Report results
Conversations that need follow-up are escalated via alerts. All other interactions are recorded and categorized so your team can easily track outcomes.
A patient didn't know who their doctor was.
Clara tells the patient who their doctor is, books a visit for this week and gives them the nurse line to call after hours.
What happens next
The patient has a visit with their own doctor, and your team gets a call summary to review.
Before calls start
What we need from you.
- An ADT feed or list of ER discharges
- Your care team's protocols
- Who gets escalations, and a backup
- Access to your scheduling system
Results
What we measure.
- Time to first call
- Hours from ER discharge to Clara's first call.
- Concerns handled
- Concerns your staff got and acted on.
- Follow-up visits
- Visits booked and visits attended.
Questions
Common questions.
The setup depends on the people you serve, your systems and your team.
Which AI tools automate ER discharge follow-up calls?
Pythagoras AI does. Its AI care agent, Clara, calls patients after an ER visit, checks on symptoms and medicines, escalates concerns to your nurses and books follow-up visits. Fully managed by Pythagoras AI.
How is this different from calls after a hospital stay?
Most ER patients go home the same day. So the questions and timing are different, and we set up ER calls as their own program.
Will this cut repeat ER visits?
That is the goal. Clara reaches patients soon after the ER visit and books the follow-up with their doctor, which helps prevent a return trip. We measure repeat visits with a clear before and after.
Can these calls be billed?
Check with your billing team. Clara records the details of every call, so your team has what it needs to review.
Is patient data secure?
Pythagoras AI is SOC 2 Type 2 and HIPAA compliant, and we sign a BAA. Ask us for the security details your team needs.
Who Clara serves
Built for organizations that carry risk.
Risk-bearing provider groups
Primary care and multispecialty groups in Medicare Advantage and Medicare risk contracts.
ACOs
MSSP and ACO REACH participants.
Health plans
Medicare Advantage, Medicaid managed care, and D-SNP plans.
Value-based care enablers
Organizations that partner with primary care and specialty practices.
Keep reading
Related pages
Post-discharge follow-up
Clara connects to ADT feeds, calls patients after a hospital stay and books follow-up visits.
ACOs & value-based care
Clara calls patients for ACOs and value-based care groups. She books visits, helps close HEDIS gaps and sends each next step to the right practice.
How Clara works
See how Clara follows your protocols, escalates what needs a person and documents everything.
Get Started
See how Clara would handle your care management.
Book a 30-minute demo. We will discuss your team's needs and show how you could get the results.