Effective Hospital Discharge & TCM with AI Nurse
Reduce Readmissions, Improve Patient Outcomes & Free Up Your Care Team
Proven 65-75% reduction in readmissions for high-risk patients, including asthma, COPD, CHF
Fewer readmissions post-surgery, including orthopedic and cardiac
Automated, human-like follow-up for medication adherence, symptoms, and recovery
SDOH risks identified and patients connected to resources & ER alternatives
5-10x productivity boost for nurses and care managers through automation
Simple implementation & EHR integration
Clinical Validation, Proven Reduction in Readmissions
With over 250,000 patients managed, Florence has proven effective in managing episodic discharge events and long-term management of high utilizers.
Based on an independent study at University Hospital of North Midlands, Florence outperformed the control group at 30 days, three and six months: Emergency Readmissions were down 66% to 70% and other Hospital Readmissions were 40% to 45% lower.
Source: Heart Failure Test Bed University Hospital of North Midlands
Boost Your Team's Productivity Tenfold, Fully Integrated with Your EHR
Florence is proven to significantly increase the capacity of clinical teams (she can follow up with more patients) and reduce cost through automation. Florence reduces the team burden by automating all routine management. She only escalates to human colleagues when required.
“Four in 10 hospitals have struggled to appropriately discharge patients due to staffing shortages”
How Does it Work?
Imagine a trusted nurse having frequent conversations via text with your patients to proactively manage and support them after their hospital discharge. Florence follows agreed protocols and is human-like in her understanding of patients. She takes on all routine work and can notify her human colleagues when required. In the hours and days just after discharge Florence may (depending on protocol) engage the patient multiple times per day. Here are some examples of ‘conversation topics’: which will vary by protocol:
Why?
Allows risk assessment and monitoring (e.g. SNF utilization)
Examples of Action Florence can take
• Ask further questions
Why?
Understands SDoH risk
Examples of Action Florence can take
• Ability to direct patient to community resources
Why?
Typically key objective is connection with PCP
Examples of Action Florence can take
• If no provider: direct patient
• Potential notification to care team if no appointment within [x] days
Why?
Medication adherence is key, also captures related SDoH (e.g. transport, affordability)
Examples of Action Florence can take
• Potential notification to pharmacy team
• Direct to community resources
Why?
Detects deterioration early, provides advice
Examples of Action Florence can take
• With potential notification to care team (based on trend)
Why?
Empirically key indicator of readmission risk
Examples of Action Florence can take
• Provide advice, potentially encourage to use Urgent Care
• Potential notification to care team
Quick Configuration with Protocol Library
From generic discharge and TCM protocols to those that are condition and/or cohort specific, we have a library of tested protocols that can be configured to your patient cohort, care setting and resources with minimal effort.
Why?
Condition-agnostic starter protocol for reducing readmissions
Examples of Action Florence can take
• Checks patient safely at home or SNF
• Confirms access to PCP and medications
• Identifies readmission risks (e.g., “feeling of deterioration”)
• Screens for SDOH risks (food, transport, etc.)
Why?
Meet CMS TCM requirements while addressing key transition risks
Examples of Action Florence can take
• Includes 30-Day Readmit Prevent components
• Structured around CMS TCM requirements
• Confirms access and communication with PCP within required 7 or 14 day timeframe
Why?
Supports high-risk patients with multiple conditions or frailty
Examples of Action Florence can take
• Includes 30-Day Readmit Prevent & TCM components
• Captures vital signs
• Assesses general health risks
• Focus on medication adherence
• Provides lifestyle & health advice
• Directs to relevant resources
Why?
Tailored for specific conditions with a focus on disease management
Examples of Action Florence can take
• Includes all Frail/Comorbid Discharge components
• Captures vital signs and condition-specific risks (e.g., breathlessness for respiratory conditions)
• Stronger focus on medication adherence
• Provides condition-specific lifestyle & health guidance
Video Spotlight
Hear directly from patients and clinicians about their experiences with Florence.
