Continuum is an AI care coordinator for the 30 days after a patient leaves the hospital, when follow-ups are most often missed. When a patient is discharged, the hospital’s EHR sends a discharge message, and Continuum pulls the patient’s record, orders, appointments and medications. An ingestion pipeline turns these into follow-ups with deadlines, saving each step in MongoDB Atlas so it can resume after a crash. It uses Vector Search to recognize orders even when their codes or wording change. Agents then do the work: a voice agent calls the patient, check-ins go out by text and email, and a result checker watches the EHR for proof that each follow-up happened. Every action is tracked from sent to confirmed, and a follow-up is closed only with real evidence. Coordinators watch it all live in a simple console, and anything the agent proposes waits for their approval.
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