Care transitions
Home from the hospital.Called within 48 hours.
Post-discharge outreach that reaches every patient, escalates the ones who need a person, and writes the outcome back. TCM-ready.
48-hour follow-up · TCM-ready · 14-day free trial
48-hour TCM window
- DischargedMon 2:10p
- Window48 hours
- Check-inTue 9:40a
Product screenshot of discharge follow-up inside the window.
How it works
Discharge to a documented call
Load the discharge list
The patients who left yesterday and today. A spreadsheet or a CRM export is enough to start.
Rivvi calls within 48 hours
It confirms they are home, checks on meds and follow-up, and escalates anyone who needs a nurse or a scheduler.
The outcome writes back
Reached, not reached, needs a person. Posted to Teams or the system of record so TCM documentation is not a hunt.
TCM is documented.
Proof
The call is the intervention
Transitional care management only counts if the patient is reached in the window. Staff cannot dial every discharge on a busy Monday. Rivvi can, then hands the ones who need a person to the team.
This sits next to medication adherence and inbound: the outbound follow-up, then the line that answers when they call back.
Questions
Care transitions, answered
Can AI do post-discharge follow-up calls?
Yes. Rivvi works a discharge list over voice and text: it confirms the patient is home, checks on medications and the follow-up visit, and escalates anyone who needs a person. Outcomes write back so the team can document the contact for TCM.
Does this replace a nurse?
No. It reaches everyone in the 48-hour window so a nurse spends time on the patients who need clinical judgment, not on the dialer. Anything clinical or urgent routes to a person, with the attempt already logged.
More on how the rules bind: Security and compliance