UC37: Post-Discharge Care Navigator

The Problem

20% of Medicare patients are readmitted within 30 days, largely due to incomplete understanding or follow-through on discharge instructions. Common failures include missed medication doses, unrecognized warning symptoms, and delayed specialist follow-up. Hospital readmissions cost CMS $17 billion annually and incur 30% payment penalties for high-readmission hospitals.

What the Agent Does

Initiates SMS contact on post-discharge day 1, 3, 7 (frequency configurable by care manager)
Asks structured questions about medication adherence, symptom presence, and activity tolerance
Flags "red flag" answers (chest pain, shortness of breath, fever, severe nausea) for immediate nurse callback
Provides brief educational content on medication purpose, when to seek urgent care, and scheduled follow-up appointment reminders
Tracks patient responses and generates summary report for care management team

Data Requirements

Primary Data Sources: Discharge summary (diagnosis, procedures, medications, restrictions), patient contact info (phone, SMS opt-in), medication list with patient instructions, follow-up schedule (specialist appointments, labs)
Classification: PHI/PII (name, MRN, phone number, discharge instructions)
Quality Metrics: SMS delivery rate >95%, patient response rate >60%, clinical accuracy of red-flag detection >99%
Complexity: Medium (templated workflow, conditional logic, escalation routing)
Systems: Epic (EHR integration), Care Management platforms (Optum Care Navigator, Humana-owned systems)

Score Breakdown

Criterion	Weight	Score (1-5)	Weighted
Time Recaptured	15%	4	0.60
Error Reduction	10%	4	0.40
Cost Avoidance	10%	4	0.40
Strategic Leverage	5%	4	0.20
Data Availability	15%	4	0.60
Process Clarity	15%	4	0.60
Ease of Implementation	10%	4	0.40
Fallback Available	10%	4	0.40
Audience (Int/Ext)	10%	3	0.30
Composite	100%		3.95

Why It Scores Well

Regulatory Alignment: Directly supports CMS HRRP (Hospital Readmission Reduction Program) reporting; evidence-based protocol
Implementation Speed: Workflow-based agent with minimal real-time clinical decision-making; existing EHR data flows
Scalability: Once deployed, handles high volume at low cost per patient contact
Patient Engagement: SMS reaches patients where they are; non-intrusive follow-up model
Proven Efficacy: Randomised trials show 15 to 25% readmission reduction with structured post-discharge outreach

Regulatory Alignment

HIPAA: SMS must be encrypted; patient must opt-in; audit trail required
CMS HRRP: Discharge planning and post-discharge monitoring are core quality metrics
FDA: Not applicable (care coordination, not clinical decision support)
State Telehealth Laws: SMS-based check-ins generally do not trigger telehealth licensing requirements

Sprint Factory Fit

2 to 3 sprints (discharge summary integration, SMS workflow design, escalation protocol, compliance audit)

Sprints Required: 2 to 3 sprints (discharge summary integration, SMS workflow design, escalation protocol, compliance audit)
Timeline: 4 to 6 weeks from design to pilot
Governance: Care manager review of red-flag escalations; monthly quality audits
Success Metrics: Patient response rate >60%; clinician satisfaction >4.0/5; readmission reduction >10%

Comparable Implementations

Guidehouse: Agentic AI in Healthcare Workflow Automation
CMS Innovation Center: Post-Acute Care Coordination Bundles
Health Affairs: Reducing Readmissions Through Post-Discharge Follow-Up

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