Check in after discharge, confirm the follow-up and work open care gaps against the record — with every worrying reply escalated to a named clinician on a stated clock, and no clinical advice sent.
Take discharge summaries, ADT events, problem and medication lists, and open gaps from the EHR and registry.
02
Read the consent, contact preference, language, channel and quiet hours already recorded against the patient.
Reason
03
Check the patient is still contactable and still eligible — not recorded as deceased, not currently an inpatient.
04
Assemble the check-in the discharge plan calls for: the medicines dispensed, the instructions and the follow-up.
05
Check each care gap against what the record evidences, so nobody is chased for a test that was done somewhere else.
Decide
06
Detect a reply naming a symptom, a medication problem or distress and hand it to a named clinician on the clock.
07
Detect a gap it cannot evidence, a contact it cannot verify or a consent withdrawn, and stop rather than send.
Out
08
Send only wording a clinician approved, on the recorded channel and in the recorded language, inside the agreed hours.
09
Retain the attempt, the channel, the reply as the patient wrote it, the escalation and the clock it was met on.
→Product statement
The agent contacts, listens and records inside rules a person set. Assessing a symptom, advising a patient and deciding what happens next stay with a clinician.
Example workflow
One discharge, end to end
AgentHuman
1Discharge event receivedADT discharge message, discharge summary, medication list and the follow-up already booked
2Eligibility checkedDeath indicator, current admission, attribution, consent, language, channel and quiet hours
3Check-in sentApproved wording only, on the recorded channel, inside the hours the patient agreed to
4Reply read and classifiedSymptom, medication problem, appointment question or distress — matched against the client's escalation wording
No human action required
Stages 1 to 4 run without a person in the loop — eligibility, consent and the wording are settled before anyone is asked to look. A reply that names a clinical concern ends that stretch on the spot, at any hour.
5DecisionSplits on whether the reply names a clinical concern
No escalation wording matched
Read by a clinician on the routine clock.
Clinical concern, or unclassifiable
Paged to a named clinician on the stated clock.
Named clinician
Sees the reply as the patient wrote it, the discharge plan it was sent against and the clock it arrived on, then calls, advises or escalates further.
Call the patient · Advise · Escalate further
Handled — handed back▼
6Escalated or recordedThe escalation, the clinician's action and the outcome, written back to the record and the gap list
7Reach and outcome evaluatedWho was reached, who replied, how long escalations waited and what closed, by cohort
Never reached
Patients the agent could not reach at all are counted in the evaluation, not dropped.
What should not run autonomously
Human approval stays in control
Outside the boundary — human approval required8 items
Telling a patient what a symptom means.
Advising whether to take, stop or change a medicine.
Deciding that a reply is not clinically urgent.
Reassuring a patient who reports something worrying.
Automation boundaryAgent acts unaided
✓Check in after discharge against the plan and the medicines a clinician set.
✓Confirm the follow-up appointment and chase what has to be in place first.
✓Offer the care gaps the record still evidences as open, and book them in.
✓Escalate every clinical reply to a named person inside a stated window.
Write actions run only inside the approval boundaries agreed during implementation. Judging a reply is not one of them.
Closing a care gap the record does not evidence.
Contacting a patient flagged deceased or readmitted.
Disclosing clinical detail before identity is verified.
Changing outreach cadence, wording or escalation rules.
Example output
One check-in reply, annotated
Everything the agent does with a reply is attached to the reply and the discharge plan it was sent against.
Outreach output · single replyIllustrative example
Check-in sent
Patient replied
Discharge
Escalated to
Confidence
Clinical assessment
Day 3, 19:40, SMS
More short of breath today
Heart failure
Named clinician, paged
91%
Not made by the agent
As receivedThe message that went out, the hour it went out at and the patient's own words in the language they used.
Evidence usedDischarge diagnosisWords in the replyClient escalation list
Why it did not wait for morningBreathlessness after this discharge is on the client's escalation list, and that list does not stop at 5pm.
ActionCall the patientRecord and closeEscalate further
What the score decidesConfidence decides which clock the reply lands on, never whether a person sees it. Every reply is read.
Value
Where AI adds value
The same four claims, placed at the point in the workflow where each one applies.
Where the value landsValue 01 – 04
Every discharge and open gapADT feed, discharge summary, gap list
03Eligibility & consent
Check the record before the phone
Death status, current admission, attribution, consent and what the record already evidences are read before anyone is contacted.
01Approved path
Reach the patients a call list never gets to
Check-ins and gap outreach run on the channel each patient agreed to, in their language, without someone working down a printout.
02Human review
Put every clinical reply in front of a person
A reply naming a symptom, a medication problem or distress reaches a named clinician on a stated clock, including out of hours.
04Build an evidence trail
Retain the attempt, the channel, the reply as written, the escalation, the clock it was met on and the clinician's action — on both paths.
Integrations
Typical integrations
Five system groups connect to the same agent. Which of them are in scope is decided in discovery.
EHR & discharge dataEpic · Oracle Health · MEDITECH Discharge summary · medication list
ADT & eligibility feedsADT events · HIE alerts Death indicator · current-admission check
Population health & measuresRegistry and gap lists · measure engine Care management · supplemental data
Agent
Post-discharge & care-gap outreach
Checks eligibility Reaches and listens Escalates on a clock
Aggregate outreach volume can look strong while a small number of patient cohorts carry most of the unreached contacts and most of the late escalations. Nestack reports performance by slice, not only in total.
Slice performance — reported separately, not only in aggregateIllustrative example
Slice
Failure rate
Lift
Lift vs. threshold
Status
Patients without SMS or portal
5.9%
3.7×
Review
Interpreter-assisted outreach
4.3%
2.7×
Review
Symptom replies out of hours
3.0%
1.9×
Watch
Routine screening reminders
1.0%
0.6×
Normal
Bar: lift vs. routine-reminder baseline · scale 0–4.0× · tick marks the 2.0× review threshold2 of 4 slices over threshold
Evidence-linked improvement
Every late reply changes the clock for the next one
A concern that waited too long is not closed when that patient is finally called. The fix lands in the escalation list, the clock or the rota.
Improvement cycle · five stagesSwitchback — the path turns at Improve and returns at Learn
01Detect
Escalation latency, unreached patients or wasted chases move in a cohort.
02Diagnose
Traced to the eligibility feed, the target list, the wording, the classifier or the rota.
03Improve
The escalation list, clock, rota or suppression rule is re-approved and version-linked.
04Verify
Re-run against held-out replies from the affected cohort, including the ones that were missed.
05Learn
That reply becomes a regression case and the changed rule enters the outreach runbook.
Learn → DetectThe return edge. A cadence or targeting change decides who hears from you next, so the next cycle re-reads the reach slices, not only the escalation total.
Typical build scope
Twelve workstreams across six weeks
The build scope read against the delivery timeline. Week structure follows the six-week plan — discovery, feeds and eligibility, content and routing, escalation and evaluation, channels, then production validation and handover.
WorkstreamWeek 1Week 2Week 3Week 4Week 5Week 6
01Workflow discovery and automation-boundary definition.
02ADT, discharge and death-status feeds.
03Consent, contact and quiet-hours rules.
04Eligibility and suppression logic.
05Check-in content and approved wording.
06Care-gap definitions and evidence checks.
07Reply classification and escalation routing.
08Escalation clocks, rota and out-of-hours path.
09Evaluation suite, reach slices and regression cases.
10Telephony, SMS and portal channel integration.
11Write-back to the record and care queue.
12Observability, deployment and Agent Care handover.
12 workstreams · 6 weeks · bar shows the weeks a workstream is active — several run in parallelFinal scope and sequence confirmed in discovery
Engagement tiers
What each tier includes
Rows are the capabilities named in each tier's scope. Higher tiers include everything below them.
Capability✓ in scope · — not at this tierPilotOne discharge cohortProductionProduction EHR integrationAdvancedMulti-site / payer programmes
Introduced at Pilot
Check-ins on clinician-approved wording✓✓✓
Eligibility and consent suppression✓✓✓
Named-clinician escalation on a clock✓✓✓
Baseline evaluation and reach reporting✓✓✓
Introduced at Production
Care gaps evidenced against the record—✓✓
Follow-up confirmation and prep chasing—✓✓
Two-way SMS, telephony and portal—✓✓
Recorded-language and interpreter routing—✓✓
Observability and evaluation—✓✓
Introduced at Advanced
Care-management and registry write-back——✓
Multi-site and payer-programme controls——✓
Build priceFrom $5,000From $8,000Custom quote
Final build priceConfirmed after discovery based on ADT and EHR integrations, outreach channels, care-gap scope, escalation cover, patient volume, approval controls and deployment requirements.
Separate from buildBuild pricing is separate from recurring Agent Care, which covers managed monitoring, evaluations, incidents and verified improvements after launch.
What we need from you
What you bring, and what we build with it
Each input maps to a piece of build scope and a week in the delivery timeline.
You bringWe build with it
01Your consent, contact-preference, language and opt-out rules→Consent, contact-preference and quiet-hours rulesWeek 1
02ADT, discharge and death-status feeds, and how current they are→Feed assessment, then eligibility and suppression logicWeek 2
03The discharge pathways and what each one asks patients about→Check-in content and clinician-approved wordingWeek 2
04The care-gap definitions your measure engine actually uses→Care-gap definitions and evidence checks against the recordWeek 3
05The wording that must escalate, and the clock it must meet→Reply classification and escalation routingWeek 3
06Named clinicians on the rota, including out of hours→Escalation clocks, rota and out-of-hours pathWeek 4
07Replies that were missed, and patients who were never reached→Evaluation suite, reach slices and regression casesWeeks 4–5
Nothing else is requiredDeployment, documentation and Agent Care handover are ours.
Delivery timeline
Four phases across six weeks
Phases are drawn over the weeks they actually occupy. No message reaches a patient before the escalation rota is standing, which is why week 5 is the first week anything is sent.
PhaseW1W2W3W4W5W6
DiscoveryW1
BuildW2 – W3
EvaluateW4 – W5
Pilot & LaunchW5 – W6
Week focusW1Consent, quiet hours and the wording a clinician has approvedW2ADT and discharge feeds, then eligibility and suppressionW3Check-in content, care-gap definitions and reply routingW4Escalation clocks and rota, then the evaluation suiteW5Channel integration, first supervised outreach and correctionsW6Real replies escalated on the clock, then Agent Care picks up
Reading the bandEscalation sits in week 4, ahead of outreach — the rota and the clock exist before anything is sent, not after.
At the end of W6Outreach has run alongside the existing calls and real replies have been escalated on the clock, then Agent Care takes over monitoring.
DurationSix-week plan shown · typical delivery 4–6 weeks depending on scope confirmed in discovery.
Next step · Healthcare AI agent
Build an outreach agent around your discharge and gap lists.
Show us your discharge pathways, your open care gaps and who picks up a worrying reply at two in the morning. We'll write the escalation list and the clock first, then scope what the agent may send.
