Bamboo Health Automated Transitions

Real-Time AI-Powered Care Navigation At Scale – So No Patient Misses The Care They Need

Automated Transitions deploys an AI agent with a human in the loop, the moment a patient is discharged from facilities in- or out-of-network. Structured outreach, PCP scheduling and closed-loop CMS TCM documentation happen automatically. No staff trigger. No missed compliance window. No patient missed.

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How It Works
Key Benefits
Impact

Timely, Seamless and Scalable Post-Discharge Engagement

Discharges happen every day across hospitals, emergency departments and post-acute settings. Yet follow-up is often delayed by limited cross-network visibility, manual outreach and fragmented coordination, leading to avoidable readmissions, lower quality scores and increased medical spend.

With Bamboo Health’s Automated Transitions solution, organizations can:

Detect inpatient and ED discharges in real time through Bamboo’s ADT and proprietary data network
Conduct streamlined AI-enabled outreach
Facilitate PCP follow-up scheduling with automated tools
Send automated reminders and confirm appointment attendance
Escalate complex cases to humans when clinical judgment is required
Standardize documentation to support quality reporting and compliance

Key Benefits

Reduce Avoidable Utilization & Total Cost of Care

Engage patients quickly after discharge to reduce preventable readmissions and ED revisits. Improve performance on transition-related quality measures while capturing eligible TCM revenue and protecting value-based reimbursement.

Enhance Quality & Star Performance

Support HEDIS and Star measures tied to transitions of care with reliable, documented outreach and follow-up. Leverage consistent, auditable workflows that strengthen performance across lines of business.

Scale Operational Efficiency

Automate high-volume outreach and scheduling while maintaining human-in-the-loop oversight. Expand impact across Medicare Advantage, Medicaid and commercial populations without adding staff.

Our Impact

Organizations using Bamboo Health’s Automated Transitions leverage the nation’s most powerful care collaboration network to achieve higher completed PCP follow-up rates, lower 30-day readmission rates and expanded care management capacity without additional FTEs.

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100%
discharge visibility across participating facilities, including those out of network
100%
outreach initiated within two days of discharge
2,500
hospitals and 8,000 post-acute facilities connected on Bamboo’s network