Post Procedure Follow Up Team

The problem: Post-hospitalization/post-procedure readmissions cost health systems billions a year and are penalized directly under CMS's Hospital Readmissions Reduction Program. Most of the early warning signs — worsening symptoms, medication confusion, uncontrolled pain — surface in the days right after discharge, in a phone check-in that may or may not happen, get documented inconsistently, or reach the right clinician in time. The idea: An agent places (or receives) a structured check-in call a few days after discharge, grounded in that specific patient's actual diagnosis, comorbidities, and medications. It scores the conversation against condition-specific red flags and routes the patient to one of four outcomes: urgent care referral, same-day physician callback, labs/imaging recommended, or routine follow-up — with a drafted chart note and a rationale a clinician can quickly verify. This is a natural extension of what Abridge already does (ambient conversation → structured clinical output), just pointed at a post-visit check-in instead of the exam room.

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