AI-Driven Transformation for Transitions of Care

Memora health
can support:

Keep patients and providers connected throughout transitions from the hospital to their home or other care setting.

Memora’s conversational AI supports accessible, actionable, and always-on care so that individuals feel confident in managing their health and care teams know patients have what they need to navigate shifts in their care settings.

Hospital Inpatient Discharge
Surgical Follow-Up
ED Discharge
Spotlight care Program

Hospital Discharge Support

Failed transitions of care after a hospital stay can harm patients and lead to costly and disruptive readmissions.

Automate post-discharge education and check-ins to empower patients through each step of their transition out of inpatient stays. Set the foundation for a road to better health with boosted preventive care engagement.

Impact on Transitions of Care


of patients expressed confidence in using their discharge instructions to manage their health


of patients engaged
with Memora's platform


of patients worried about a complication but were reassured by Memora's AI assistant

*Representative outcomes from discharge and post-procedural Care Programs with various health systems

A Win-Win-Win For Everyone

 Navigating transitions of care can feel overwhelming for patients and their care teams. Make coordination simple for everyone with Memora’s AI-backed, EHR-integrated Care Programs.*

Operational Efficiency

  • Reduce manual care team outreach

  • Mitigate the burden of data collection

  • Decrease patient inbound calls/messages

Enhanced Clinician &
Patient Experience

  • Boost patient satisfaction

  • Foster patient retention

  • Improve care team fulfillment

Support Financial Sustainability

  • Lower 30-day readmission rates

  • Increase post-discharge PCP visits

  • Reduce patient adverse outcomes and total cost of care

*Representative goals of Memora partners

App-less, 2-way
SMS engagement
conversational AI
Intelligent triaging &
EHR/CRM integration

Augment Your Care Team With Intelligent Assistance

Leverage AI to automate program-specific interactions via white-labeled, native SMS. With deep EHR integrations, text messages are personalized for each patient.

Hello! I can help with questions or concerns, whether they're about your discharge instructions, appointment-related questions, or managing symptoms like fever and pain. Text me whenever you need to. I'll reply instantly.
That is helpful. Can you get me a copy of my discharge plan?
We'll let your care team know that you want a copy of your discharge instructions and they'll contact you soon. You can also use the patient portal to get a digital copy of your discharge instructions and find support, resources, lab results, and upcoming appointments.
Thank you! Just logged into the portal and found them.
We hope you're feeling comfortable & settled back at home. Have you had a moment to review your discharge plan?
Yes, I did.
Is there anything in your discharge plan that confuses you or that you don’t understand?
I’m not sure.
Take a minute to open your instructions, there are a few especially important instructions for managing your home care.
Look for:
- Activity level
- General care
- Diet
- Medication instructions

I’ll check in on you in a few days.
Just checking to see if you’ve scheduled a follow-up visit with a provider?
OK. Following up with a provider within the first week of your discharge can lower your risk of returning to the hospital. Reach out to your provider to set up an appointment as soon as you can. I’ll check on you in a few days.
Thank you!
Can you tell us about what got in the way of picking up your prescriptions?
A. No transportation
B. Too expensive
C. Insurance doesn’t cover
D. I don’t think I need them
E. Something else
No transportation
We understand picking up medications without transportation can be hard, but here are some things that might help.

1. Ask a friend or family member to pick up your medications
2. Fill your prescription(s) at a pharmacy that delivers.
3. Explore local transportation options at this link.

Let us know if you need anything else.
Quick check-in, as promised! Over the next few days it’s helpful to follow your instructions. Let family members or friends be a part of your recovery after discharge. They may be able to pick up medications or take you to appointments. They may remember things that you forget about symptoms, problems, or questions you want to ask. This can help make your recovery process smoother.
Ok thank you. I will have my son help.
I’ll be checking in later to see how you’re settling and if there’s anything I can help with. Remember, you can text this number anytime if you have a question or concern about your care. To reach your care team, please follow the contact instructions given to you.
I’m feeling really stressed
We understand that life can be stressful. It's ok to feel overwhelmed and there are things you can do to feel better. Try taking several deep breaths, talking with a friend, or taking a break to do something you enjoy. Your care team is here to listen if you need help.
How should I prepare for my PCP appointment?
At your PCP follow-up appointment, make sure to bring your discharge instructions, your medication list, and any questions you have so you can talk about the next steps in your care. Your doctor will likely want to know more about what happened in the hospital, any new health concerns, and how your health has been now that you're back home.
Got it. Thank you!
In the last 30 days, have you gone to the emergency department or been readmitted to the hospital?
Thanks for taking the time to answer these questions. We’ll pass this information along to your care team.
The patient experience with Memora

“When you go home, there are questions you forget to ask before discharge and this is great to have as a resource.”

Related Resources

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