Florence | TOC Executive Brief
Transitions of Care: proven to reduce readmissions and save staff time
Florence extends the care team beyond the hospital through automated, two-way SMS. Structured post-discharge pathways reinforce the care plan, identify emerging clinical and practical barriers, support follow-up, and escalate patients who need human intervention.
Real-world evidence across post-discharge, heart failure, COPD, and emergency-care pathways shows Florence can help patients navigate the transition home while reducing avoidable acute-care utilization.
One platform. Multiple transitions-of-care pathways.
Florence can support broad post-discharge populations or layer condition-specific monitoring around patients at higher risk of deterioration and readmission.
General TCM / Post-Discharge
Structured follow-up after discharge to reinforce care plans, identify barriers, support follow-up, and escalate emerging needs.
29% reduction in 30-day all-cause readmissions
CHF Discharge
Condition-specific post-discharge monitoring and support to identify deterioration early and reduce avoidable readmissions.
56% reduction in CHF readmissions
COPD Discharge
Reinforces symptom monitoring, self-management, and rescue plans following discharge to help patients act earlier when symptoms worsen.
70% reduction in emergency COPD admissions
ED Discharge
Timely follow-up after an ED visit to address unresolved needs, reinforce next steps, and reconnect patients to appropriate care.
66% reduction in emergency attendances
From discharge signal to targeted intervention
Florence automates the repeatable work of follow-up while directing care-team attention toward the patients and issues that require intervention.
1
Trigger outreachUse discharge or ADT data to begin timely follow-up.2
Capture patient needsCheck symptoms, medications, follow-up, access, and practical barriers.3
Identify exceptionsSeparate routine recovery from responses indicating emerging needs.4
Escalate when neededSurface actionable issues to the care team for human follow-up.Real-world evidence across transitions of care
Hospital deployments provide additional evidence that structured, automated post-discharge support can be associated with lower 30-day readmissions while identifying patients who need help after discharge.
St. Michael's Medical Center
Newark, NJ | March–May 2026
44%
lower relative risk of 30-day readmission
7.0%Florence
61 / 872
61 / 872
12.6%Comparison
48 / 381
48 / 381
n=1,253 | RR 0.56 | 95% CI 0.39–0.79 | p=.001
Roxborough Memorial Hospital
Philadelphia, PA | 2025 comparative cohort
41%
lower relative risk of 30-day readmission
6.2%Florence
26 / 418
26 / 418
10.6%Control
107 / 1,009
107 / 1,009
Calculated RR 0.59 from reported counts.
Engagement that moves the transition forward
Florence does more than send a discharge message. Patients respond, complete post-discharge pathways, reconnect with follow-up care, and surface needs that may otherwise remain invisible.
73%completed a 30-day post-discharge program
63%confirmed a follow-up visit at Roxborough
58%reply rate among Spanish-speaking patients at Roxborough
88NPS for St. Michael's discharge outreach
Post-discharge outreach surfaces actionable barriers
At St. Michael's, Florence handled 983 inbound messages from 362 discharged patients, revealing specific medication and follow-up needs. Early Medicaid ED-discharge data from CCHA similarly shows how outreach can identify both clinical and social barriers.
103St. Michael's patients with PCP-access issues
142patients reporting medication difficulties
75patients without a scheduled follow-up appointment
51%of St. Michael's discharge patients engaged (687/1,353)
CCHA early-stage Medicaid ER transitions-of-care analysis; n=291 completed patients. Question-specific denominators vary because not every patient responded to every prompt.
Built for scale across populations and care models
Florence can use existing discharge signals to create a consistent post-discharge pathway across large, distributed populations without requiring a separate manual outreach model at every site.
300K+
Medicaid members
CCHA supports more than 300,000 Medicaid members across multiple Florence clinical programs, including transitions of care.
40 → 250
Medical groups
Pearl Health's distributed Medicare ACO rollout began across 40 medical groups, targeting 250, using ADT data and internal risk scores.
4 weeks
From data feed to TOC launch
CCHA launched a transitions-of-care program within four weeks using existing data feeds.
One pathway, configurable care-team involvement
Organizations can start with the operating model that fits current capacity and deepen integration over time.
Automated follow-upConsistent post-discharge outreach without routine escalation monitoring.
Targeted escalationDefined patient needs are surfaced when selected triggers warrant care-team follow-up.
Expanded integrationBroader notifications and escalation workflows embed Florence more deeply into care management.
A more consistent transition from hospital to home.
Florence combines scalable outreach with patient-reported data and targeted escalation, helping care teams maintain continuity through the post-discharge window while focusing human attention where it can add the most value.
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