AI Readmission Prevention

Problem

Use Cases

Features

ROI

Demo Calls

Section 01

Problem

A 30-day readmission risk cannot be managed with one call on day three.

The problems that return members to the hospital often emerge after traditional follow-up has ended: a prescription was never filled,an unreported complication, a direction not understood, there is no transportation to the next appointment, or a member with heart failure begins gaining weight on day eleven and does not call anyone.

AI Readmission Prevention maintains contact throughout the full 30-day discharge window. It checks for changes in symptoms, medications, appointments, and recovery; helps resolve routine barriers; and escalates emerging clinical concerns before they become an emergency department visit or inpatient stay.

The human benefits are obvious, but the economics are just as significant. An avoided readmission represents approximately $18,000 in cost, while the intervention is often straightforward once the risk is identified.

The challenge has never been knowing what to look for. It has been reaching every discharged member often enough to find it in time.

Section 02

Use Cases

Sepsis
CHF
COPD
Device-complication
Pneumonia
Diabetes
AMI

Section 03

Features

Features:

Post-discharge outreach at 24-72 hours with repeat cadence across the full 30-day window.
Symptom detection with severity grading across 8 clinical categories and red-flag escalation to a live RN mid-call, under clinically proven nursing guideline escalation protocols.
Post-discharge medication reconciliation — compares the discharge list against the pre-admission list and catches stopped, changed, and duplicated medications (Med Stoppage supervisor model).
Labs and vitals interpretation with Vital Sign Clarification supervisor model.
Acoustic Bio-Marker supervisor model — HealthCUES detects a cough inside a live conversation and classifies it (dry, wet, barking, whooping) in roughly a third of a second, for CHF, COPD, and pneumonia surveillance, catching the symptom the member never mentioned.
Caregiver Speech and Caregiver Rapport supervisor models for family communication.
In-call booking of the follow-up visit and transportation.
Reading Between the Lines / Implicit Understanding supervisor model.
Multi-call Memory across the transition.

Contributed to a 30% reduction in readmission rates at UHS.

Section 04

ROI

~$18K avoided per prevented readmission; 3pp readmission reduction (published, conservative). ER diversion: 0.12–0.15 ED visits avoided per engaged member per year; $1,400–1,800 saved per avoided visit.

Section 05

Demo Calls

Nuanced Clinical Eval

Care Coordination (Discharge)

Labs and Vitals.mp3