Track recovery, manage co-morbidities, and monitor health indicators for patients after discharge.
PDCM is a patient management application built for the critical post-discharge window — where clinical outcomes are determined but clinical oversight is reduced. The platform connects care coordinators, primary care physicians, and patients in a structured recovery management workflow.
From surgical recovery tracking to co-morbidity management, PDCM monitors health indicators in near real time — alerting clinical teams to deterioration before it becomes readmission, and keeping patients engaged in their own recovery through a dedicated mobile app.
The PDCM care coordinator dashboard surfaces patient status, alert flags, and engagement scores across the post-discharge cohort in real time.
Monitor post-operative recovery, wound care adherence, and early warning signs for surgical site complications.
Track vital signs, medication adherence, and activity levels for post-cardiac event patients during the high-risk recovery window.
Manage chemotherapy side-effect reporting, appointment adherence, and quality-of-life indicators between hospital visits.
Coordinate long-term care for patients with diabetes, COPD, and renal disease discharged after acute episodes.
PDCM changed how we think about the discharge moment. We used to see discharge as the end of our responsibility. Now we treat it as the start of a 30-day engagement. Our cardiac readmission rate has fallen by 43% in the first two quarters.
Our care coordinators now manage 40% more post-discharge patients than before — not because we hired more people, but because the dashboard surfaces only the patients who need attention. Everything else is monitored automatically.
Every implementation is different. These are the questions we hear most often — answered directly, without the sales wrapper.
PDCM integrates via HL7 FHIR R4 APIs, supporting Epic MyChart, Cerner PowerChart, Oracle Health, and Meditech. The integration is configured during onboarding — typically 4–8 hours for standard FHIR-enabled EHRs. Post-discharge progress notes, vital sign readings, and alert events are pushed back to the EHR automatically, maintaining a complete longitudinal record.
PDCM supports SMS-based check-ins as a full fallback pathway. Patients receive structured SMS questions at configured intervals and respond by text. Responses are parsed by the platform and fed into the same monitoring dashboard as app-based data. Telephone check-in workflows are also available for high-acuity or elderly populations.
Alert latency is under 2 minutes from threshold breach to notification. Thresholds are configured per condition and per individual patient risk profile during discharge. Alerts are delivered via the web dashboard, email, and SMS simultaneously. Escalation paths — from coordinator to on-call physician — are configurable per department.
Yes. PDCM ships with pre-configured pathways for cardiac surgery, orthopaedic surgery, oncology, bariatric surgery, and general surgery. Each pathway defines the monitoring schedule, health indicator set, patient-facing questionnaire, and alert thresholds relevant to that specialty. Custom pathways can be configured in 2–3 days by your clinical team using the pathway builder in the admin portal.
The 40% figure is the average reduction observed across our health system deployments, measured over the first 6 months of operation against the preceding 12-month baseline for the same patient population and surgical cohorts. The range across deployments was 29%–54%. Our internal validation report provides the full methodology, inclusion criteria, and site-level breakdowns — available on request from your account team.