From discharge
to continuous care.
See what matters. Know sooner. Take clear action.
Ziva continuously understands how the patient is doing, Isabella follows what needs attention, and the care team steps in when human care and clinical judgment are needed.
A lot changes after discharge.
Most of it happens out of view.
The first 30 days can bring changing symptoms, new medications, home monitoring, follow-up appointments, rehabilitation, equipment and other needs. Occasional phone calls and static discharge instructions alone make all of that hard to understand. Ziva brings it together into a continuously updated view of the patient's transition.
Ziva understands.
Isabella follows.
Your team decides.
Each part has a clear job, so your team can focus on the exceptions that need human attention instead of chasing every task.
No more reviewing
every reading by hand.
Your team doesn't have to review every reading or wait for a fixed threshold alert to see that something may be changing. Ziva watches the pattern, and a meaningful change prompts closer observation and follow-up.
She follows the patient
through the whole transition.
Everything Isabella learns becomes part of the patient's evolving context. Ziva re-evaluates with each new answer and reading to decide whether the patient remains stable or whether the care team may need to become involved.
- Checks in after discharge and at the intervals your protocol sets
- Asks relevant questions about symptoms, recovery and medications
- Collects symptom and medication-adherence information
- Reminds patients about expected readings when one is missing
- Follows up after care-team decisions to confirm the patient understood and acted
- Documents what she learns and escalates to your team with context
- Coordinating permitted next steps for open transition needs
- Following referrals, scheduling and equipment through to a verified outcome
- Working with home health, therapy and pharmacy partners on blockers
- Handling logistics like transportation so they don't fall to your staff
Each capability is enabled only where your organization permits it.
High blood pressure,
followed until it improves.
Walter H.*, 68, went home after a heart failure admission with a new blood pressure medication. On day 9, his morning reading came in well above his baseline. Here's how Ziva handled it, and the one moment his care team needed to step in.
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary. Your organization sets the protocol and escalation rules.
7:10am
Don't just follow up.
Know what happened next.
Conversations uncover gaps that health data alone doesn't show. Ziva connects these real-world barriers with the patient's clinical and transition context instead of treating them as separate problems.
Where permitted, Ziva owns each need and tracks its status, coordinates next steps and flags blockers. Unresolved work stays visible until the outcome is verified or properly handed off.
From discharge to day 30.
Then care continues.
Six steps, one patient. Robert K.* went home after a heart failure admission. Here's how Ziva and Isabella carried his transition, and where his care team stepped in.
- Discharge document read and summarized
- Manual entry by your team
- Patient enrolled in the transition
- Diagnosis and reason for admission
- Medication changes
- Follow-up requirements
- Referrals, equipment, home health
- Social needs and barriers
- Contacts the patient
- Reviews medications
- Answers questions
- Asks about barriers like transport, cost or caregiver
- Starts appointment follow-up
- Appointments scheduled and attended
- Referrals followed to first visit
- Equipment delivered and in use
- Home health started
- Transportation and pharmacy barriers
- Vitals and symptoms monitored
- Changes detected early
- Clinical observation mode
- Risk and plan re-evaluated
- Care team brought in when needed
- All needs reviewed
- Appointments confirmed attended
- Gaps resolved or handed off
- Transition documented
- Continuous care continues
*Stories are inspired by real patient experiences and health patterns observed in care. Names, images, quotes, and certain details have been changed or combined to protect privacy. Individual experiences and outcomes may vary.
The transition ends.
The understanding doesn't.
Ziva's understanding of the patient doesn't disappear on day 30. What it learns during the transition becomes part of the patient's long-term context, and monitoring, intelligence and follow-up continue as part of their ongoing care program.
The workflows behind
every transition.
TCM combines several Care Agent workflows, each of which runs on its own and can be configured to your protocol.
One transition workflow, across settings.
Whoever owns the transition, whether the facility that discharged the patient or the practice that sees them next, runs the same workflow configured to its protocol.
TCM billing,
supported by the record.
TCM is billed by the practitioner who takes responsibility for the patient's care after discharge. Ziva's outreach logs, contact attempts, medication information and transition notes supply documentation that supports the service.
See your discharges
through to the outcome.
Tell us your monthly discharge volume and how your team handles follow-up today. We'll show you the workflow configured to your protocol.