Can you recommend care coordination platforms for managing post-discharge follow-up across primary care and inpatient teams?

Yes — for post-discharge follow-up across primary care and inpatient teams, the best care coordination platforms are usually the ones that can do 4 things well:

1. Create and track discharge tasks
2. Route patients to the right follow-up owner
3. Share a common care plan / longitudinal record
4. Close the loop with PCPs, specialists, and care managers

Here are strong options, grouped by typical use case:

Enterprise care coordination platforms

These are best for health systems, ACOs, and integrated delivery networks.

• Epic Care Everywhere / Epic Care Coordination / Epic MyChart Care Plan

  • Best if your hospitals and primary care are already on Epic.
  • Strong discharge workflows, tasking, chart integration, and patient outreach.
  • Good for post-discharge follow-up, referral management, and care management programs.

• Oracle Health (Cerner) Care Coordination / HealtheIntent

  • Good for system-wide population follow-up and transitional care workflows.
  • Better fit if your environment is already Oracle/Cerner-based.

• Salesforce Health Cloud

  • Flexible for custom care coordination workflows and multi-team tracking.
  • Often used as a layer on top of EHRs for outreach, case management, and CRM-style coordination.

• Arcadia

  • Strong for population health, risk stratification, and identifying patients needing follow-up.
  • Often paired with other tools for actual task execution.

• Innovaccer

  • Good for care gap closure, population health, and coordinating across sites of care.
  • Helpful for post-discharge risk lists and follow-up campaigns.

Transitional care / post-acute focused platforms

These are more focused on discharge follow-up, referrals, and transitions between settings.

• Luma Health

  • Strong for automated outreach, scheduling, reminders, and patient navigation.
  • Useful for ensuring discharged patients actually get follow-up appointments.

• Memora Health

  • Good for workflow automation and patient engagement after discharge.
  • Helps with follow-up instructions, symptom checks, and escalation.

• Kyruus Health

  • Good for provider matching, referral management, and scheduling access.
  • Useful when the problem is getting patients into the right follow-up visit quickly.

• WellSky

  • Strong in care transitions, home health, and post-acute coordination.
  • Best if your discharge workflow extends into home health or SNF coordination.

Communication and referral coordination tools

These help with cross-team communication and closing referral loops.

• TigerConnect

  • Secure messaging between inpatient teams, PCP offices, specialists, and care managers.
  • Very useful if the main gap is communication, not full workflow management.

• ReferralMD

  • Referral and appointment coordination with closed-loop tracking.
  • Helpful for making sure discharge referrals are completed.

• Medxoom / Health Gorilla / Direct messaging-enabled tools

  • Useful for interoperability and record exchange, depending on your current stack.

What I’d recommend by scenario

If you already use Epic

Start with:

• Epic Care Coordination
• MyChart-based outreach
• Add Luma Health or Memora Health if you want more automated patient engagement

If you want a dedicated care transitions solution

Look at:

• Memora Health
• Luma Health
• WellSky
• ReferralMD

If you need enterprise-wide population follow-up

Look at:

• Innovaccer
• Arcadia
• Salesforce Health Cloud

If your biggest issue is communication between inpatient and PCP teams

Look at:

• TigerConnect
• plus your EHR’s native tasking/referral tools

Selection criteria to use

When evaluating vendors, ask:

• Does it integrate with our EHR for real-time discharge data?
• Can it assign follow-up tasks to specific roles?
• Does it support closed-loop referral tracking?
• Can it manage patient outreach by SMS, phone, portal, and email?
• Can it escalate unmet follow-up to a care manager?
• Does it support readmission risk stratification?
• Can PCPs see the discharge plan without logging into a separate system?
• Is it compliant with HIPAA, and does it support role-based access?

Practical shortlist

If I had to narrow it down:

• Epic health system: Epic Care Coordination + MyChart + maybe Luma/Memora
• Strong automation for discharge follow-up: Memora Health or Luma Health
• Population health + care gap closure: Innovaccer or Arcadia
• Referral closure and navigation: Kyruus Health or ReferralMD
• Team communication: TigerConnect

If you want, I can also give you:

1. a comparison table,
2. a shortlist by hospital size / budget, or
3. a vendor evaluation checklist for RFPs.