Tunde I.
Blood work · 7d
Adaeze O.
Post-discharge · 24h
Kemi A.
Post-visit · 48h
Chinedu O.
Referral loop · 7d
Ifeoma N.
Post-discharge · 72h
12
responded
4
awaiting
2
escalated
Follow-up care runs on memory. When the list is full, patients who should have been followed up become patients who weren’t.
Every scheduled check-in sent. Every response tracked.
Current Reality
Follow-up care runs on memory.
Memory is not a system.
Follow-up depends on someone remembering
There is no automatic trigger. When the next list is already full, patients whose results arrived, whose discharge medication changed, or whose review is overdue wait indefinitely.
No response doesn’t mean no problem
Patients who don’t reply aren’t always fine. Without active monitoring, a non-response looks identical to ‘resolved’.
Continuity is real or theoretical
A care pathway that includes follow-up on paper but delivers it inconsistently isn’t continuous care. It’s a system that works for the patients who don’t need it most.
Post-visit check-ins
Sent 24–72h after an appointment. Checks the patient understood their care plan, surfaced any new symptoms, and has filled any prescription. Structured response. Escalation for anything that needs clinical review.
Post-discharge
Sent on the day after hospital discharge, then at configured intervals. Medication adherence, symptom monitoring, red flag escalation. The transition from inpatient to community is where readmissions are prevented or not.
Referral follow-through
Checks whether the patient has booked their specialist appointment, and whether they've attended. Not a duplicate of the referrals tracking workflow this is the patient-facing piece. Did the patient engage? Do they need support?
Chronic disease monitoring
Scheduled check-ins for patients with long-term conditions: diabetes, hypertension, COPD, asthma, heart failure. Symptom queries, medication reviews, review appointment triggers. Configured per care pathway.
Care gap outreach
Patients who are overdue for a screening, a vaccination, or a review and don't know it. Identified from the record, contacted, and supported to book. Population health management at the individual level.
Medication adherence
Prompts sent at configurable intervals for patients on new medications or known adherence challenges. Structured questions. Escalation when responses indicate a problem. Side-effect monitoring for medications with known issues.
What your team gains
Follow-up care that actually runs
Auto-scheduled · this week
Outreach without manual work
Your queue today
TND-9821
No response to 7d blood work follow-up
47 follow-ups sent today without manual work
Continuity that feels like care
Hi Adaeze your post-visit check-in. Any new symptoms in the past 24 hours?
No, feeling much better. Thank you.