Care after a hospital stay
The first month home is when patients most need someone to call. Contact within two days, a visit within two weeks, and the handoff on one record from the first day.
For the first month after a hospital stay.
Patients going home after a stay need a call, a visit, and medications that make sense, in that order and soon.
Patients this works well for
- Patients going home after a hospital or nursing facility stay
- Medication changes made at discharge
- Patients who need a visit in the first two weeks
- Caregivers who need to know who to call
Patients better served elsewhere
- Patients past their first month home who need ongoing care
- Patients who check in from home between routine visits
- One serious condition that needs a named coordinator
- Ongoing care for complex conditionsMonthly follow-ups for patients with two or more long-term conditions, with one care plan and one care team on the same record.
- Follow-up care from homePatients check in from home between visits. Your team sees what changed, acts early, and the record is written as it happens.
- Focused care for one serious conditionIntensive follow-up for a single high-risk condition, with a plan the whole team can see.
Your team brings the patient home. Hoss Care keeps the handoff whole.
The calls, the reconciliation, and the visit stay with your clinicians. Hoss Care brings the discharge in and keeps every step on the record.
What your team does
- Calls the patient within two business days
- Reconciles medications with the patient
- Sees the patient within two weeks
- Reviews, edits, and signs every note
What Hoss Care does
- Puts the discharge on the team's list the day it arrives
- Brings the summary and medication list into one chart
- Flags medication changes for the nurse to check
- Prepares the claim with the signed notes attached
AI assistance in Hoss Care is advisory. It suggests and flags; your clinicians review, edit, and sign, and your staff submit.
From discharge to day thirty.
The handoff, the call, the visit, and the record, in the order they need to happen.
A handoff that does not drop.
The discharge summary, the medication list, and the follow-up plan arrive in the chart together, before the patient gets home.
- Discharge summary and medication list in one chart
- Medication changes checked against what the patient took before
- Caregivers know who to call
- Every step on the record by day thirty
Questions practice managers ask
How do we find out about a discharge?
When the discharge reaches your EHR, it appears on the care team's list with the summary and medication list attached. Discharges that arrive another way can be added to the same list by hand.
What has to happen in the first month?
Contact with the patient or caregiver within two business days, medications reconciled, and a face-to-face or video visit within the first two weeks. Each step is a task on the list, with the note attached when it is done.
Does the AI reconcile medications?
No. AI assistance can flag a possible duplicate or change on the discharge list for the nurse to check. The nurse and the clinician reconcile medications with the patient and sign the note.
How does billing work?
When the first month closes, the claim is prepared with the signed notes from the call and the visit attached, ready for your billing team to send.
Home, and staying there. Every step of the handoff on the record.
Ready to run the first month after discharge?
See how Hoss Care runs the first month home on the record your team already uses.