Care that keeps going after discharge
Hoss Care gives health systems one place to run follow-ups, care coordination, and documentation across every site, inside the EHR you already have.
What health systems are up against at every site.
From discharge to population health, the work is the same everywhere: follow-ups, coordination, and documentation that holds up.
Follow-up after discharge
Patients leave the hospital, and the follow-up call depends on who remembers to make it.
In practiceA discharge summary sits in a shared inbox over the weekend, and the first call happens on Tuesday.
Coordination across sites
Every facility keeps its own list, and the handoff between them is a phone call.
In practiceThe cardiology clinic and the primary care office each call the same patient, on the same day, about different things.
Quality goals at year end
Quality measures are reported at the end of the year, long after the gaps could have been closed.
In practiceA missed screening surfaces in the annual report instead of at the patient's next visit.
Care team capacity
Nurses and care managers spend more of the day documenting than talking to patients.
In practiceThe afternoon goes to typing up calls that were finished before lunch.
The same record, a better day for every role.
Coordinators, nurses, physicians, and quality leaders each see the part of the work that is theirs. AI assistance suggests and flags; people decide.
- Care coordinators
Discharges land on one list
Discharges from every site arrive the same morning, with the call and the follow-up visit booked from the same screen.
- Nurses
Changes flagged for review
Check-ins from home that need attention are flagged. The nurse decides what happens next.
- Physicians
Notes suggested, signed by you
AI assistance suggests the follow-up note. The physician reviews, edits, and signs.
- Quality and operations
Care gaps in view all year
Gaps show up while there is still time to close them, site by site, on the record your teams already use.
Built into the systems you already run.
Our team handles the technical work. Referrals come in from the EHR, and signed notes go back to the chart, with the security bar a health system expects.
- Epic, Oracle Health, MEDITECH, and athenahealth
- HL7 and FHIR, with ADT feeds for admissions and discharges
- Lab results and pharmacy systems on the same record
- HIPAA compliant with a signed BAA; SOC 2 Type I report available on request under NDA
- Single sign-on, role-based access, and audit logs
Care your teams run between hospital visits.
Each one runs as a documented workflow on the record your teams already use, from the first call after discharge to the long-term plan.
- Care after a hospital stayA follow-up call soon after discharge, a visit on the calendar, and the handoff on one record from the first day home.
- 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.
- Value-based careQuality measures, care gaps, and attribution tracked in the same record your team already works in.
Every discharge on a follow-up list. Every one of them documented.
Ready to see it on your sites?
Health systems use Hoss Care to keep follow-ups on schedule, close gaps earlier, and document the work while it happens.