Solutions
Care Transitions Pilot
A 90-day pilot model for Medicare Advantage plans, ACOs, and health systems to improve post-discharge engagement, comprehension, and secure escalation to care teams.
Core Problem
Patients frequently leave acute care settings unsure about medications, follow-up actions, and warning signs. This creates avoidable engagement failures, missed follow-up, and transitions-of-care risk.
Pilot Objective
Demonstrate measurable improvement in post-discharge patient engagement and comprehension through secure AI-assisted guidance and care-team escalation workflows.
Phase 1 Scope
Patient-facing plain-language summaries and contextual guidance.
Secure escalation workflow to care teams for follow-up.
Weekly KPI governance with gate-based progression.
Out of Scope in Phase 1
Enterprise-wide rollout and production bidirectional EHR write-back. These are addressed only after pilot success gates are met.
Deployment Models
Vendor-Hosted
Fastest launch model with lower internal infrastructure overhead and managed application operations.
Customer-Hosted Cloud
Customer cloud-account ownership with managed operations and control over account-level governance.
On-Prem / Private Data Center
For strict locality and network controls. Air-gapped variant is available for highly restricted environments.
Security Baseline
Minimum-necessary PHI handling aligned to role and workflow.
Request-scoped AI context with zero-retention processing pattern.
Role-based access controls and tenant-aware isolation.
Auditability across access, prompts, responses, and escalations.
Pilot KPI Set
7-day post-discharge engagement rate.
Patient comprehension confirmation rate.
First-response time to patient escalation.
Escalation closure time and ownership clarity.
Pilot Delivery Timeline
Architecture and security workshop
Confirm deployment model, data boundaries, escalation paths, and go-live gates with clinical, operations, and security stakeholders.
Integration and readiness validation
Validate data flow, role-based access, auditability, and pilot workflow readiness across required teams.
Pilot operation and optimization
Run live workflows for discharged members with weekly KPI review, issue resolution, and rapid operational tuning.
Outcomes synthesis and scale plan
Publish pilot readout, compare outcomes against baseline, and define scale-up recommendation with deployment roadmap.
Next Step
Start with the Week-1 Architecture Workshop
We align clinical workflow, security controls, and deployment model first, then lock pilot gates and implementation timeline.
Schedule Workshop