Post-discharge follow-up
Follow up with patients after a hospital stay.
Clara, the AI care agent from Pythagoras AI, connects to ADT feeds (alerts when a patient leaves the hospital) and calls recently discharged patients. She checks on symptoms, reviews medications with the patient and schedules follow-up visits. She keeps checking in through the readmission risk period and escalates via warm handoffs or alerts based on clinician-developed, customizable protocols. Fully managed by Pythagoras AI.
After a hospital stay
20x your care management teams by keeping them focused on top of license work.
Clara follows clinical and admin protocols, only escalating to your team when needed.
Clara
Follow-up after a hospital stay
“Are you having trouble getting or taking your medications as prescribed?”
“I haven’t been able to pick them up since I got home from the hospital and I’m almost out.”
“You have refills left on your prescription. Would you like me to send an order to the pharmacy to have them delivered to your house?”
Summary
Patient couldn’t get their medicine. Clara ordered a refill delivery to their home. Clara has documented the patient’s new address.
- Send to
- Care team
- Next step
- Staff reviews and marks reviewed
The problem
Patients get readmitted after discharge for avoidable reasons
Most avoidable readmissions start with a problem at home in the first few days, like a missed medicine or a new symptom. Your team often doesn't hear about it until the patient is back in the hospital.
Their medicines are wrong or missing
The patient hasn't picked up the new prescription, or is still taking a pill the hospital stopped.
What Clara does: Checks their medicines against the discharge plan. She orders a refill delivery if she's connected to the pharmacy, and tells your nurse about anything that doesn't match.
A new symptom gets worse at home
The patient notices swelling, dizziness or shortness of breath but doesn't call anyone. When it gets bad, they go to the ER.
What Clara does: Asks about symptoms on every call. If something is wrong, she follows your protocols and makes a warm handoff to a nurse when it's urgent.
The follow-up visit never gets booked
The patient doesn't see their doctor after leaving the hospital, so nobody checks how they're doing or changes their care plan.
What Clara does: Books the visit during the call and sets up a ride if they need one.
No one is there to help at home
The patient lives alone, or the family member helping them was never told the discharge plan.
What Clara does: Asks who helps them at home and lets your care team know if they need more support.
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.
Listen
Hear a post-discharge call
Listen to Clara call a patient after a hospital stay.
Listen to a post-discharge call
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.
What Clara asks
Sample questions customizable to your protocols.
- How have you felt since you got home?
- Do you have any new symptoms, or have any got worse?
- Do you have your medicines, and are you taking them the way your discharge plan says?
- Do you have questions about the care plan you took home? Is anything unclear?
- Have you booked your next visit? Do you need a ride?
- Do you have the help you need at home?
What Pythagoras does
We manage Clara. Your team stays in charge.
We set up Clara, oversee conversations and fix problems. Your team leads patient care.
Your team approves the protocols
We draft the approach based on our templates and your existing protocols.
We manage outreach and quality
We quality assure conversations and keep improving Clara.
Your team leads patient care
Clara completes routine tasks under your protocols. Your care team stays top of license, handling what needs clinical judgment.
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.
FAQ
Questions care teams ask us
Which AI tools automate post-discharge patient follow-up?
Pythagoras AI does. Its AI care agent, Clara, handles transitions of care outreach. She connects to ADT feeds, calls patients after a hospital stay and escalates under your protocols.
What if a patient reports a serious symptom?
Clara escalates under protocols your care team approves, with a warm handoff in an emergency. Clara does not give medical advice.
When does Clara call after discharge?
Clara calls once your ADT feed shows the discharge, at the times you prefer. We report call attempts and answered calls as two numbers.
How long does Clara keep checking in?
Clara keeps checking in through the readmission risk period, on the schedule your protocols set. Alerts and escalations show up in real time in your care management software.
Can Clara book a visit?
Yes. Clara books the visit in your scheduling system under your practice rules.
Which languages can we use?
Clara speaks 35+ languages. Tell us which languages your patients speak and we will set them up.
Does Clara work with our health record system?
Yes. Clara connects to ADT feeds, your EHR and care management software.
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.
What does fully managed mean?
We build, customize and manage Clara. Your team approves the protocols, receives reporting on outcomes and leads patient care.
Keep reading
Related pages
ED discharge follow-up
Clara calls patients after an ER visit. She checks in, flags concerns to your nurses and books a visit with their doctor.
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.