Selected tools, tips, and resources for ADT workflow management
Turning ADT Alerts into Actionable, Timely Care
What happens after a patient leaves the hospital is just as important as the care they received while admitted, and ensuring a smooth transition from hospital to home is crucial for both patient outcomes and practice performance in value-based care. Proper transition of care management isn’t just a checkbox—it’s a critical factor in reducing readmissions and supporting recovery. Yet too often, patients leave the hospital with limited guidance, unclear instructions, and fragmented support for coordinating follow-up care. This is where primary care should play a central role: empowering PCPs to identify at-risk patients and lead post-discharge follow-up can make all the difference.
At Pearl Health, we believe succeeding in risk-based models depends not just on having the right care team, but also on executing workflows that maximize patient outreach, scheduling, and high-impact transitional care. That’s why we created the ADT Toolkit: a structured, easy-to-use resource designed to help clinical teams respond with confidence and consistency when patients transition from hospital to home. Whether you’re part of a health system or an independent practice, our toolkit offers step-by-step guidance to help build or strengthen consistent, patient-centered follow-up processes for ADT alert response.
Why ADT Alerts Are a Crucial Lever in Value-Based Care
As health systems and physician groups take on more risk, real-time ADT alerts have become essential for proactive care coordination. These alerts improve visibility into patient hospitalizations and give primary care teams the opportunity to intervene early by reviewing discharge plans, reconciling medications, or scheduling timely follow-up. Yet many practices aren’t notified when their patients are admitted to or discharged from the hospital or emergency department. Without this critical information, they can’t coordinate follow-up care or support recovery—making gaps in clinical data one of the biggest barriers to improving outcomes.
Even when ADT alerts are available, having clear processes and dedicated resources makes all the difference in responding effectively. Pearl’s ADT Toolkit is designed to support that work—equipping care teams with structured workflows and practical guidance to strengthen transitions of care, reduce avoidable utilization, and ensure patients receive timely, coordinated follow-up after hospitalization.
What’s Inside the Toolkit?
- Selected Best Practices: Key actions high-performing practices use to stay on top of transitions of care, like reviewing and updating EHR templates, assigning team members to review alerts daily, conducting timely medication reconciliation, and prioritizing interactive patient outreach.
- Example Post-Discharge Workflows: Step-by-step guidance to streamline engagement, pre-visit prep, follow-up, and documentation. By clearly assigning roles and standardizing handoffs, practices can improve care coordination and ensure patients receive timely, reliable support throughout their recovery.
- Outreach for High-Value Interactive Contact: Effective outreach goes beyond scheduling—it involves assessing symptoms, reviewing medications, and reinforcing discharge instructions. We’ve included an outreach guide with sample scripts and best practices to help care teams identify barriers to care, coordinate services, and engage patients during this critical transition period.
- Billing Requirements: Clear recommendations on how to accurately document post-discharge follow up, including Transitional Care Management (TCM) coding information. The Toolkit outlines key documentation and timing requirements and links to additional billing resources, such as a past office hours session on TCM best practices.
- Resources: A curated library of supplemental materials to support implementation and scale, including EHR documentation templates, care team assignment guides, patient outreach scripts, and Medicare TCM service requirements. External resources like AHRQ’s RED Toolkit, PRAPARE, and POLST forms by state are also included to support clear communication, risk screening, and care planning.
From Reactive to Proactive:
Enabling Smooth Transitions of Care
The ADT Toolkit helps care teams shift from reacting to hospital discharges to proactively managing transitions of care. With structured workflows, clear team roles, and actionable outreach tools, primary care providers and their care teams can engage early: anticipating needs and intervening before complications occur.
By guiding teams through processes like daily alert reviews, pre-visit planning, and timely medication reconciliation, the Toolkit promotes consistent, high-quality follow up after hospitalization. The result is a more confident, coordinated response that helps reduce readmissions and improve outcomes.
Built for the Frontlines—With You in Mind
Pearl’s ADT Toolkit reflects a broader philosophy: to meet provider organizations where they are, and equip them with the tools to thrive in value-based care. Whether you’re just getting started or refining existing workflows, we’re here to help you bridge the gap between ADT alerts and the timely, patient-centered decisions they demand.
Want to learn more about how Pearl’s platform and clinical programs support ADT-based interventions?
Reach out to our team to explore how we can work together.
