Workflows/Post-Discharge Care Transition — M-5541
22 decisions · 21 governed
4
DP

Post-Discharge Care Transition — Member M-5541

In ProgressStep 3 of 5
Started 7 Aug 2026, 10:00 · Triggered by discharge notification from Valley Medical
DP
David Park, Care Coordinator
Process Timeline
Discharge Record Retrieval
07 Aug, 10:00 – 10:02 (1m 38s)
Retrieved discharge summary, medication list, follow-up instructions, and diagnoses from Valley Medical Center ADT feed and claims system.
6 records from 3 systems
Auto-verified
Care Gap Identification
07 Aug, 10:02 – 10:06 (3m 52s)
Analyzed discharge instructions against member's current care status. Identified 4 care gaps: PCP follow-up, cardiology referral, medication fill, weight monitoring enrollment.
10 sources — claims, pharmacy, scheduling, EHR
Auto-verified
CRITICAL: PCP follow-up not scheduled. 7-day window closes 13 Aug 2026. Member has no appointment on file.
Outreach & Coordination
07 Aug, 10:06 – ongoing
Executing care coordination actions: member outreach for PCP scheduling, cardiology appointment confirmation, pharmacy coordination for discharge medications.
2 of 4 coordination actions completed
Member contact required for PCP scheduling
Intervention Plan Assembly
Compile personalized intervention plan including scheduled follow-ups, medication adherence monitoring, and CHF weight program enrollment.
Coordinator review and member consent required
30-Day Readmission Risk Check-In
Automated 30-day post-discharge assessment: verify completed follow-ups, medication adherence, and readmission risk re-scoring.
Auto-scheduled for 5 Sep 2026

Step 3: Outreach & Coordination

In Progress
What the agent is doing
Coordinating follow-up services identified in Step 2. Tracking completion status for each care gap and facilitating scheduling, referrals, and pharmacy actions.
Coordination Actions
PCP Follow-Up Scheduling — Member has not responded to outreach (2 attempts: voicemail 7 Aug, SMS 8 Aug). Third contact attempt due today.
Cardiology Referral — Appointment confirmed with Dr. Nakamura, 18 Aug 2026. In-network verified.
Discharge Medication Fill — Pharmacy contacted. Furosemide covered under formulary. ACE inhibitor requires prior auth (submitted 8 Aug, pending).
Weight Monitoring Enrollment — Pending PCP follow-up (enrollment requires PCP order per plan protocol).
Governance Checkpoint
Member Contact Required
PCP follow-up scheduling requires member engagement. Two contact attempts documented with no response. Protocol requires care coordinator to attempt direct phone call before escalating to community health worker outreach.
Evidence for This Step
Discharge summary — Valley Medical, 6 Aug 2026
ADT notification — admission/discharge/transfer feed
Pharmacy claims — formulary status for furosemide, lisinopril
Provider directory — Dr. Nakamura availability and network status
Member contact log — 2 attempts documented
Four Pillars
Meaning: Care transition → NCQA HEDIS FUH measure (Follow-Up After Hospitalization within 7 days). CHF → ICD-10 I50.x series.
Process: Step 3 of 5 per care transition workflow CT-WF-001
Evidence: 10 sources verified, 2 coordination actions confirmed
Record: EB-2026-0807-HP-02356-S3 · 10:06:44Z