Real-Time Post-Acute Care Insights Made Possible Through EDCC

Ansible Health is a multispecialty medical group providing hospital capacity support and post-acute care for high-risk patients with chronic conditions such as heart failure and COPD. These patients often move between emergency departments, inpatient units, skilled nursing facilities, and home—frequently across multiple health systems—making care coordination challenging.

Ansible Health CEO Jack Po explains, “These patients tend to bounce around many, many hospitals… and it’s incredibly difficult to get medical records or even figure out where the patient is.” This lack of visibility is especially dangerous in the days immediately following discharge, when “around half of 30-day readmissions happen within the first three days.”

Through the EDCC program, Ansible Health gained real-time insight into patient admissions and discharges across care settings. Today, the team actively monitors more than 10,000 patients nationwide, including 1,000+ in Virginia, allowing them to intervene during the most critical post-discharge window. “The ability to know very quickly where a patient is and what their background is has completely revolutionized outcomes for us and for those patients,” Jack says.

That speed translates directly into better care, making sure medications are filled, oxygen and DME are delivered, and follow-up happens before patients decline. Patients notice the difference. “They tell us, ‘How do you know I just left the hospital?’” Jack shares. “That magical ability lets us make sure everything is in place.”