Support transitional care after every discharge
Support Transitional Care Management (TCM) with first contacts scheduled within the TCM window, structured follow-up after discharge and early identification of patients who need attention, helping prevent avoidable readmissions and ED visits.
Contact at the moments that matter, with alerts for the cases that need review
Contacts begin once the patient leaves the hospital and follow the schedule set for each discharge pathway, from the first 24 hours up to 30 days. The focus is recovery after the acute episode, not ongoing monitoring of the underlying condition.
Each contact collects how the patient has been feeling since leaving hospital, alongside symptoms, warning signs and home measurements included in the protocol.
Contacts check whether the patient has started the medication prescribed at discharge and is taking it as indicated, and record any questions about changes to their treatment, which are passed on to the care team.
Responses outside the protocol’s criteria generate alerts, and the care team decides the next step. Each review is documented with a clinical note and the care plan. When the window ends, the team closes the episode or refers the patient to their usual care or to a long-term programme.
Protocols for diferent types of discharge
Protocols grounded in clinical practice guidelines and refined across previous implementations.
Outcomes in the weeks after discharge
“Since we started using LOLA, hospital admissions for acute deterioration have been avoided in 6 out of 10 cases. It helps us reach a broader patient population with the same team and anticipate when a condition may worsen.”
The value of follow-up when patients return home
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Every Discharge Contacted Within the TCM Window
Contacts start within two business days of discharge and are documented for the care team, supporting your TCM program.
Medication Issues Caught Early
Unfilled prescriptions and medication questions reach the care team, supporting medication reconciliation after discharge (HEDIS TRC).
Fewer Avoidable Readmissions
Issues surface in the first days at home, before they lead to an ED visit or readmission, supporting HRRP and HEDIS PCR performance.
Discharge is one step in the pathway, not the end
Preparation for tests and surgery
Before the same procedure: patients arrive prepared and procedures are not cancelled.
Chronic and long-term care
When the post-discharge period ends and the patient needs ongoing follow-up.
Access and demand management
Reviews arising from follow-up are booked, confirmed and rescheduled without going through the team.
