HealthPulse analyzes EHR data (diagnoses, vitals, meds), social determinants (housing, transport access), and post-discharge behavior (med adherence via app logs) to predict 30-day readmission risk. High-risk patients trigger:
- Nurse call within 24 hrs of discharge.
- Free Uber Health ride to follow-up.
- Medication delivery reminder SMS.
Model retrained weekly with new outcomes. Epic EHR integration ensures real-time data flow. Dashboard shows risk scores per patient for care coordinators.