Customer story · An independent multi-specialty group
The day’s work beside the chart.
- What changed
- Today’s actions, a short brief and consent sit beside the chart.
- Who checks
- Physicians decide what to act on.
Health Systems
Manage readmission risk and episode cost.
Fold gives every eligible patient leaving the hospital an owner and a follow-up plan, so fewer come back and episode costs stay on target.
Every milestone to day 30 has an owner.
At discharge, Fold gives contact, the follow-up visit and the readmission watch each a named owner.
- Day 0Hospital dischargeThe clock startsOwner Transition of care AI agent
- 2 business daysInteractive contactRequired for TCMOwner Jordan Reyes, RN
- By day 7Face to face visit for 99496High complexity MDM, med rec by the visitOwner Dr. R. Hayes
- Or by day 14Or that visit for 99495At least moderate MDM. One visit, one TCM code.Owner Dr. R. Hayes
- Through day 30Readmission watchHRRP for eligible hospitalsOwner Jordan Reyes, RN
Nurses review the draft without leaving the chart.
AI agents draft, your nurse signs, and filing completes only after the EHR confirms receipt.
Contact note signed inside the EHR
Patient chart
Raymond Carter78 · heart failure
- Contact noteNot filed yetOpen
Contact noteDrafted by the transition of care AI agentDrafting
- Contact with patient and his wife
- Medications reviewed with Daniel Wright, PharmD
- Visit Mon 11/2 · Dr. R. Hayes
Built from the call transcript
To sign · Jordan Reyes, RNSigned by Jordan Reyes, RNFiles only after she signsFiles after signingTask stays open until receipt
Fold prepares each discharge case before the nurse calls.
Fold merges the discharge summary and medication flags into one case and suggests an owner.
Hospital discharge case prepared for a nurse
Signals · Raymond Carter
- ADT A03 dischargeSt. Mary’s 6 East
- Discharge summaryC-CDA via HIE
- Warfarin at homeMedication AI agent
Merged into one case for the care team
Raymond Carter · TCM case78 M · heart failure
SummaryMedicationsVisit
Contact by Thu 10/29
No owner yet
Suggested for Jordan Reyes, RNAccepted by Jordan Reyes, RNHF panel · Tue 11:33 AMPanel rule · HF to the HF panelApplies to eligible HF discharges
Have Transitions of Care evidence ready when the visit is signed.
Fold keeps each discharge as one case from admission alert to visit, with a named owner and evidence for each HEDIS Transitions of Care (TRC) indicator.
One episode, admission to TRC evidence
Raymond Carter · care episodeSt. Mary’s 6 East to Northside Family Medicine
Admission noticeFri 10/23 · ADT A01
DischargeTue 10/27 · summary
ContactWed 10/28 · RN
VisitMon 11/2 · Dr. R. Hayes
RHVisit note to sign · Dr. R. HayesVisit note signed by Dr. R. HayesMed rec goes on the visit note
Assembling TRC evidenceMeasure validation pending
Transitions of care, TRC · HEDIS MY2026
0of 4 indicators with evidence attached
- Notification of inpatient admission
- Receipt of discharge information
- Patient engagement after discharge
- Medication reconciliation post discharge
Get reviews to the payer complete and on time.
AI agents match evidence to payer criteria for authorizations, concurrent review and appeals. UM nurses and physicians decide.
Health system utilization review
Inpatient authorization packet
Raymond Carter, inpatient staySt. Mary’s 6 East · admitted Fri 10/23
Chart evidence · heart failure admission
- Shortness of breath at restEHR note
- BNP elevated on arrivalLab
- Pulmonary edema on chest X-rayImaging
- IV diuretic started in the EDEHR note
Gathering evidencePayer deadline for clinicals Mon 10/26, 5:00 PM
KMUM nurse · Karen Mitchell, RNReviewed by Karen Mitchell, RNDecides what is sent to the payer
Same chart, through the stay and after
- Concurrent reviewClinical update for the payer’s next review
- Denial and appealPacket assembled with the evidence
Your UM team decides what is sent
Three goals that depend on follow-up.
For each one, Fold prepares the follow-up work and gives it an owner.
01Readmissions
Bring down 30-day readmissions under HRRP.
At applicable hospitals, contact is tracked to two business days with the summary and medication list prepared, and a readmission watch runs to day 30.
02Episode cost
Keep episode spending and quality on target.
For TEAM hospitals, eligible surgical episodes run through 30 days after discharge. CJR-X joint replacement episodes run through 90 days, beginning January 1, 2028.
03TCM
Bill the eligible TCM services your clinicians provide.
Contact and visit windows for 99495 and 99496 tracked, documentation prepared for clinician review.
Does Fold replace our EHR’s population health tools?
No. Keep them. Fold reads the same events, prepares the work and writes the result back.
How is Fold different from an AI that makes calls or reads charts?
Many AI tools do one step and hand the rest back to your team. Fold carries the case through your rules, the schedule and the chart, and your people sign what they must.
What does Fold need from our IT team?
Admission and discharge feeds, patient matching, chart access and a note filing path; we scope the rest together.
Do physicians need a new login?
Not where your EHR supports SMART on FHIR launch. Fold opens from the chart with your single sign on.
Who makes the discharge call and reconciles medicines?
AI agents compare the medicine lists, flag each change and prepare the reconciliation for a named clinician to review and sign. They also help reach the patient and book the follow-up visit. A clinician, nurse or clinical staff member makes the discharge call. An AI agent call never counts as that contact.
Trace one patient from discharge
to a signed note.
We review your interfaces and AI governance, then confirm how signed work could return to your EHR.
Book a demo