ExpressAgainFor discharge and transitional care programs
The first weeks after discharge, where your transition team can see them.
For hospital transition teams, transitional care programs, post-acute and discharge services and care-transition nurses. The family records the discharge date, the medications with every dose change, the doses given or missed and the readings typed at home. Your team sees its first contact after discharge in business days, alerts against your own targets, and every patient in the program on one panel.
30 minutes on Zoom with our founder. Nothing to prepare.
A physician practice billing transitional care? See the practice page.
The gap
The patient goes home. The picture your team needs stays behind.
The discharge date lives somewhere else
The day the patient went home is in the hospital's system, not in front of the team that has to call. The first follow-up depends on someone remembering.
The medication list changed on the way out
A dose went up, a new one started, an old one stopped. The family goes home with a printout, and the next person to see the patient may not know what changed or who ordered it.
The first weeks at home are quiet until they are not
A blood pressure creeping up, a missed evening dose or a fall reaches the team only if the family calls, and nothing is written down in one place.
The family is left to run the handoff
Appointments, call-backs, pharmacy runs and what the nurse said on the phone all land on one family member, one call at a time.
The first days home
The discharge date, the first contact after it, and what each call decided.
ExpressAgain runs in the web browser on a phone, tablet or computer; there is nothing to install. Enroll the patient by email or text, the family accepts, and the record starts where the hospital stay ended.
Admission and discharge dates on the record
On the Care Team page, Log a call or visit lets the family record a hospital admission and the discharge date, an emergency room or urgent care visit, or the EMT coming out, with the day, the time and who was involved. Your clinicians log the same encounters on the care dashboard. A typed discharge shows who typed it.
Log a call or visit →The first contact after discharge, in business days
The Billing support report runs the transitional care checks: the discharge on record and where it came from, "Contact within 2 business days of discharge", and the visit within 7 or 14 days, each met or not yet. A contact is the first team feed post, clinical note, time entry or logged call or visit after the discharge day. Weekends are skipped; the app has no holiday calendar.
Billing support →The result of every call
A logged call carries what the nurse or doctor said to do: Appointment scheduled, Go to the ER, Go to urgent care, Call back after checking something (like blood pressure), Medication change, or Advice given, no follow-up needed. The result is what your clinician said; the app never gives advice.
Log a call or visit →The follow-up visit on the calendar
When the family logs a call whose result is Appointment scheduled, with the day, the time, the doctor and the address, the visit goes on the patient's Appointments and Schedule by itself. A time that is already taken is never double-booked; the family is told what holds it.
Appointments →Coming Home, for the family
Checklists that help the family walk into the discharge conversation ready, and the therapy team's home recommendations filed by category, each marked Done, In progress or Need help. Every list is a prompt to confirm with the patient's care team.
Coming Home →
See it with one of your own discharges in mind.
Request a demo
See the first days after discharge
Walk through the discharge date on the record, the first contact from your team counted in business days, the result of each call and the follow-up visit on the family's calendar.
Rather pick a time now? Book a 30-minute demo.
Medications at home
The new orders, the doses due, and who gave each one.
The medication list the family keeps, with every change the doctor ordered, and a dose log the whole care team reads.
The medication list with its dose history
Each medication keeps every change the doctor ordered: started, increased, decreased, changed, paused, resumed or stopped, the day it starts, the dose before and after, and who ordered it. Every recorded change is a line on the team feed. A physician, nurse, hospice or palliative login can record a change from the Medications tab. The app records what was ordered; it does not check or suggest doses.
Prescriptions and the dose history →Scheduled doses and the dose-due pop-up
Each medication can carry its times from the label. When a set of doses is due, a pop-up asks whoever logs doses, naming each medication, its strength and how much: Given now, Given earlier, or Given, Skipped or Refused one by one. If the window closes with the set not logged, it asks again and offers Mark as missed.
Medication schedules and the dose-due reminder →Given, skipped, refused or missed
Every dose logged by the family, a Home Team professional or your clinicians carries who logged it and when. The Medications report counts given, skipped, refused, late and missed doses, with a Dose changes section, and the weekly home summary carries the same count.
Health reports →
See the dose history and the dose-due pop-up on a phone.
Request a demo
See the medications at home
Walk through the medication list with every dose change the doctor ordered, the dose-due pop-up, and the doses given, skipped, refused or missed, as the family and the Home Team log them.
Rather pick a time now? Book a 30-minute demo.
Readings and alerts
Readings typed at home, checked against your clinicians' own targets.
Readings are typed by people, never sent by a device. Your team sets the targets, and a reading outside them reaches your clinicians as one plain line.
Home readings, typed by the family
Blood pressure and pulse, glucose before and after meals, temperature, oxygen, weight, symptoms such as a fall, swelling or nausea, sleep and meals. Readings are typed by the family, a Home Team professional or your clinicians, and every entry carries who logged it. The chart records and displays; it never judges a value.
Health Tracking →Your clinicians' own targets
The family types the ranges and when-to-call instructions your team gave them, and a clinician on the care team can update them from the Care targets tab. Each group shows who changed it last and when, for example Updated by Dr. Sample, and the change is a line on the team feed.
Targets, when to call, and care alerts →Care alerts
Every reading becomes one plain line for your clinicians, such as Glucose, breakfast before, above target, and a reading outside the targets goes out at once. The rule is your numbers; a care alert is not a diagnosis. Texts say only that a new alert needs a look, with no values.
Targets and care alerts →Acknowledging and escalation
Your team acknowledges flagged alerts on Feed and alerts. Set an escalation window in minutes for each location: when a flagged alert waits longer without an acknowledgment, the primary and covering providers are emailed.
Feed and alerts, and escalation →
See a reading go outside the targets, and the alert it sends.
What your program gets
Every patient in the program, on one panel your team can read.
All of it is live today, except where a line says it waits on a vendor, on activation or on a signed BAA.
The organization panel
Every patient in the program on one screen: last reading, open alerts and how old they are, unread feed and enrollment status. Tap a row to open that patient's whole dashboard, and the bell counts what is new.
The organization panel →Enrolling a patient
Enroll a patient by email or text; the message names your organization, never the patient, and the family accepts. Add covering colleagues or a coordinator, resend while it waits, and see the program's patients in one list.
Enrolling patients and coverage →Preview before the agreement
Before the agreement is signed, your organization is in preview: providers see the patients whose families added them, and a few patients can be enrolled to see how it works. When that runs out, Book a call takes its place.
Preview and signed organizations →Archive, with a reason
When a patient leaves the program, Archive asks why: moved to another facility, discharged from the program, passed away, the family ended it, or another reason with a note. It ends the enrollment and every access, and the patient stays under Archived with the reason and the date.
The organization panel →The IDC Team feed
The Care Team's own conversation: every discipline and the family post and pin, with a row for each reading, dose and dose change logged, with initials and the time. Clinicians leave notes the family reads.
The IDC Team feed →Reports and the weekly home summary
Vitals and glucose, medications, symptoms and alerts, the visit flow sheet and a weekly home summary. 7, 30 or 90 days, Print and CSV, the same report the family reads.
Health reports →Billing support, as documentation
When your package includes Billing-ready exports, the monthly report documents the time your clinical team logs, the contacts, consent and the transitional care checks, with Print and CSV. It never picks a code, and every figure is labelled an estimate. Estimate only. What's paid depends on your payers, your documentation and each claim.
Billing support →Chart records, from the family's portal
Chart records come from the family's own patient-portal connection (Epic MyChart, eClinicalWorks healow), read-only, and nothing is written back to your chart. The connections are built; each one activates as the vendor approves the app.
Doctor's Records →The Partner API and HL7
The Partner API reads what families shared with your organization and pushes readings and documents back, with every call logged; keys are issued after a signed BAA. The HL7 v2 feed is built and pending activation.
Partner API documentation →
See the panel with your own program in mind.
Request a demo
See your program's panel
Walk through enrolling a patient, the family accepting, readings against your targets, care alerts and escalation, the reports your team reads and archiving a patient who leaves the program.
Rather pick a time now? Book a 30-minute demo.
Outcomes
Built for fewer missed follow-ups, medications given as ordered, and problems at home seen sooner.
Fewer missed follow-ups after discharge
The discharge date on the record, and the first contact after it
The family or your team types the discharge date, and the Billing support report shows your team's first contact after it, counted in business days, with a link to the place that fixes a check not yet met.
Billing support →Medications given as the new orders say
Every dose change the doctor ordered, and a dose-due pop-up
Each medication keeps its history: started, increased, decreased, paused or stopped, the day it starts and who ordered it. When a set of doses is due, a pop-up asks whoever logs doses, and a scheduled dose nobody logged counts as missed in the Medications report.
Prescriptions and the dose history →Problems at home seen sooner
Readings against your own targets, care alerts and escalation
Readings typed at home are compared with the targets your clinicians set. A reading outside them goes out to your clinical logins at once, and a flagged alert nobody acknowledges within your escalation window goes to the primary and covering providers.
Targets and care alerts →A family that knows what happens next
The result of every call, and the appointment on the calendar
When the family logs a call, they write down what the clinician said to do: an appointment scheduled, go to the ER, call back after checking blood pressure. An appointment the family logs goes on the patient's Appointments by itself, unless that time is already taken, and Coming Home walks the family into the discharge conversation ready.
Appointments →
A pilot measures these with you, in your own patients.
Book a 30-minute demoHow discharge programs work with us
The same packages as hospitals, starting with one program.
Ways to work with us
Departmental Pilot
Six months in one department or service line, with the patient capacity and scope agreed together.
Department License
The department keeps going after the pilot, under its own license.
Hospital Enterprise License
Every department in the hospital, under one license.
Health System Agreement
Several hospitals and departments under one agreement.
Integration
EHR, HL7, FHIR, single sign-on or custom work, scoped per agreement.
Discharge program pricing is set with each program on a call; it is not published.
How a pilot works
From a demo to your first patients enrolled.
A 30-minute demo
We walk through the discharge date on the record, the first contact after it, the medications and dose history, readings against your targets, care alerts and the program's panel.
Scope a six-month pilot in one program
Pick one program: a transition team, a transitional care clinic, a post-acute service or a readmission-reduction program. Agree the patient capacity and scope together, then sign the agreement. We sign a Business Associate Agreement with partner organizations once our vendor agreements are complete; that is in progress now, so ask us for the timeline.
We set up your organization and train the program
Our team creates your organization and adds the first person, in whatever role fits. We train the program's team; once the agreement is signed, your administrators invite their own clinicians, and the program enrolls patients by email or text.
Grow from the pilot
From the pilot into a department license, a hospital-wide license or a health-system agreement across several hospitals and departments.
What clinicians say
From the pilot practice.
These are clinicians at the physician practice piloting ExpressAgain.
This is very helpful.
This is all in one. Convenience is everything, and this is super convenient.
Why we built it
I built ExpressAgain for my mother, Debbie. Five lesions on the left side of her brain took her speech, not her mind. She still has so much to say — now she has the tools to say it.
Questions
What discharge programs ask us.
See the first weeks after discharge the way your team would. Start with a 30-minute demo.
Pick a time that suits you, or tell us what you need and we will reach out.
Request a demo
Talk to us
Tell us about your program, who it follows after discharge and what you are trying to solve. A real person replies within one business day.
Rather pick a time now? Book a 30-minute demo.
One team, one plan
Built for the interdisciplinary care team
An interdisciplinary care team is a group of different health professionals who work together closely with the patient and family to create a single, shared treatment plan. ExpressAgain is the platform where all of those parties care for one patient together: the same day, the same medications, the same notes, and the same record of who did what and when.
Family
the daughter, the siblings, the friends who show up
Home care
aides hired directly or sent by an agency
Clinicians
nurses, therapists, hospice, palliative, paramedics
Agencies
the office that staffs, schedules and bills