Follow-up care built around the discharge list
Readmissions often start with a follow-up that never happened. Hoss Care puts each discharge on a care team's list, documents each contact during the call, and keeps the record inside the EHR your system already runs.
What gets in the way after discharge.
Follow-up across a health system fails in the gaps between departments.
Readmissions that were preventable
A patient goes home, the follow-up call slips, and the same patient is back in a bed within the month.
In practiceThe discharge summary is in the chart, but nobody owned the call on day two.
Thousands of patients, no single list
Long-term conditions across a whole system are tracked in spreadsheets and inboxes, so the patients who need a call this week are hard to find.
In practiceA case manager exports a report on Monday that is already out of date by Tuesday.
Data split across departments
Cardiology, primary care, and the discharge team each see a piece of the patient, and nobody sees the whole picture.
In practiceA medication change in one clinic is not visible to the nurse making the follow-up call.
Handoffs that do not land
Discharge instructions are given once, at the bedside, and rarely confirmed after the patient is home.
In practiceThe patient could not read the printout, and there was no second contact to catch it.
One follow-up workflow across a health system.
Built for the size of a hospital, not clinic software stretched to fit. AI assistance suggests and flags; your care teams review and act.
One workflow across every department
Roll out the same follow-up workflow across service lines, with one dashboard and access set by role.
In practiceA nurse in cardiology and a case manager in primary care work the same list from the same record.
- Epic
- Oracle Health
- Care team
Every discharge on a follow-up list
A contact soon after the patient gets home, a follow-up visit booked, and the handoff documented from the first call.
In practiceThe follow-up call is on the right person's list the morning after discharge, with the discharge summary attached.
- Discharge
- Follow-ups
- Documentation
See who needs attention this week
Patient lists sorted by risk, so the team calls the patients most likely to come back before they do.
In practiceMonday's list shows which patients discharged last week have not checked in yet.
- Readmissions
- Quality measures
- Care coordination
Built for the size of a health system.
Every feature is designed for care across departments, service lines, and large patient panels.
- Epic, Oracle Health, and athenahealth integration
- Rollout across departments and service lines
- Population dashboards by service line
- Follow-up scheduled at discharge
- Patient lists sorted by risk
- Access set by role
- Claims prepared with the note attached
- Quality measure reporting
Care services your teams can run after the hospital stay.
Follow-up after discharge, ongoing care, and wellness visits, documented during each contact so the record supports the claim.
- 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.
- 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.
- 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.
- Integrated behavioral healthScreening, follow-up, and care coordination for mind and body in the same visit workflow.
- Annual wellness visitsThe yearly visit prepared for, risks flagged, and the gaps closed before the patient leaves.
Every discharge on a follow-up list. The aim is fewer patients back in a bed.
Ready to organize follow-up after discharge?
See how Hoss Care helps hospitals and health systems organize follow-up after discharge and keep documentation current across departments.