Program · runs under transitions of care
Post-dischargeThe weeks after a discharge decide whether the patient comes back.
Patients in the window after an inpatient stay, when contact is thinnest and the risk of coming back is highest.
The discharges
The admissions it follows home.
The window after these stays is where the return trip is decided — and it is exactly where contact is thinnest. The program starts from the discharge itself: the new medications, the follow-up that should exist, the history the patient is returning to.
Heart failure stays
The new diuretic, the weight, the breathing
COPD exacerbations
The rescue plan, the inhalers, the next flare's early signs
Pneumonia
Finishing the course, and whether recovery is actually happening
Cardiac events & procedures
New medications started in the hospital, kept going at home
Stroke
The regimen, the follow-up, and what changed about daily life
Major surgery
Recovery instructions, warning signs, the post-op visit
Sepsis recovery
The slow weeks after, when a setback looks small at first
Observation stays
Sent home without an admission — and without a discharge planner
You decide which discharges enroll and where escalations go. Contacts are weighted toward the earliest days — when the new medications are still unfamiliar and the follow-up visit is not yet on the calendar.
The contact
What each contact follows.
Several contacts across the weeks after discharge, weighted toward the first days when risk is highest and contact is thinnest.
Every attempt ends as a recorded outcome — so who was actually reached this month is a fact your team can pull, not a guess.
Voice call · early in the window
“You came home Tuesday with a new water pill. Have you been able to start it, and has anything changed with your breathing?”
Followed on every contact
- Whether discharge instructions were understood and are being followed
- New or worsening symptoms since going home
- Whether the discharge medications were filled and started
- Whether the follow-up appointment is booked and reachable
The split
The routine part completes on the contact. The rest reaches the care team.
Completed without a clinician
- Getting the follow-up visit on the calendar
- Routing a medication that was never picked up
- Re-delivering discharge teaching that did not land
Text message · after the call
Sent to the care team
- Symptoms suggesting the original problem is returning
- A medication the patient never started, or stopped
- Anything the patient describes that the call is not scoped to answer
An escalation arrives with the transcript, the triggering sentence, and the change against this patient’s own baseline — in the patient’s own care team’s queue, ranked by severity.
The escalation rules are written and certified by our clinicians before any patient is contacted. How programs are designed.
The handover
What the care team receives when the window shows a problem.
Not an alert with no reason. The finding, the patient's own words, the change against their baseline, and what LifeWatch deliberately did not do — in one artifact.
Escalation · delivered to the care team
Weight rising since discharge with new breathlessness at night
Delivered
Within a minute of the call ending
Why this was raised
Triggering statement
“I have been waking up needing to sit forward. And my shoes are tight on me again.”
- Change from baseline
- Four pounds above the weight recorded at discharge six days ago.
- Sent to
- Her own care manager, with the covering clinician copied
Escalated because it meets criteria written into this program by our clinical team and reviewed with your organization before go-live. LifeWatch applies the rule; it does not decide what the rule should be.
What the care team received
- The transcript, with the triggering statement marked
- The change against her own discharge baseline
- Her conditions, current medications, and the discharge medication change
- What the call covered, and what it deliberately did not answer
- Why the program treated this as urgent
What LifeWatch did not do
- No diagnosis was offered
- No medication or dose was changed
- No treatment advice was given
- The patient was told a nurse would call, and nothing more
Running the program
- What it writes back
- A record of the transition contact, what was found, and where it went — attached to the patient's timeline.
- Who owns it on your side
- Transitions of care. The program reports into the readmission work that team already owns. It adds the contact in the window, not another list to staff.
- What a pilot measures
- Share of discharged patients reached inside the window, and the share whose follow-up appointment was booked before it lapsed. Agreed before the pilot starts — the only honest form of proof we offer.
Start with last month's discharges.
The useful first conversation is about a real window: who went home, who was reached, and what your team wishes it had known sooner.
Talk to our team