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AshvinDuoTM + KNOAH · For Acute Care Hospitals

Your work doesn't end at discharge. Now your visibility doesn't either.

Track every patient across SNFs, ALFs, SLFs and Home — automatically. AshvinDuo™ + KNOAH gives your providers continuous post-discharge visibility, proactive alerts, and AI-generated patient summaries — with zero staff lift and no expensive outreach agencies.

See it on your discharges How it works
Trusted by CMOs, care coordination leaders, and population health teams across the country.
Built for CMOs, Care Coordination, Discharge Planning & Population Health
Epic Cerner HL7 FHIR CMS HRRP HIPAA
The reality after discharge

You treat the sickest patients in the country — and then they walk out your doors.

Everything you've done — the surgery, the medication titration, the careful plan — rests on what happens next. And what happens next is a black box. Here's what we kept hearing.

Discharge is a blind spot

The chart goes dark the moment the patient is wheeled to the curb. You hear from them again only if something goes wrong.

Outcomes depend on others now

SNFs, ALFs, home health, and families are doing their best. But their visibility is your liability.

Non-adherence is invisible

Skipped meds, missed PT, gradual weight gain — nobody flags it until the patient is back in your ED.

Readmissions become penalties

Every avoidable bounce-back is a CMS payment cut — and an HRRP penalty that follows the hospital for a year.

Manual tracking burns millions

Outreach agencies, call-center reps, transitions-of-care programs — large bills, modest lift, unsustainable at scale.

Calls happen too late

A 14-day check-in catches the patient who's been deteriorating since day 4. The window for intervention is already closed.

Families feel abandoned

"Once we left the hospital, nobody called." The discharge experience defines the relationship — and the survey scores.

You only learn what you missed

The morbidity-and-mortality review tells you what happened. You needed to know two weeks earlier.

Reputation rests on what you can't see

Star ratings, payer relationships, community trust — all decided in the 30 days you have no visibility into.

"We do everything right inside the building. Then we hand them a phone number and hope."
— Chief Medical Officer, 600-bed academic system.

The breakthrough

AshvinDuo™ + KNOAH — continuous clarity for everything that happens after discharge.

The first fully automated, intelligent post-discharge monitoring platform built for acute care hospitals. Every patient. Every facility type. Every day. No call centers. No staff lift. No more black box.

You define what matters. We watch for it — twenty-four hours a day, across SNFs, ALFs, SLFs, and Home — and bring it to your providers the moment it matters.

Post-discharge visibility engine

Every patient, every facility — one live cohort view, continuously refreshed.

Readmission-prevention intelligence

Risk scoring that updates with every signal — heart rate, weight, adherence, mood.

Configurable rules engine

Your clinicians write the rules. The system enforces them. Round-the-clock.

Patient, family & caregiver engagement

One platform, three audiences — the right message to the right person at the right time.

Digital companion in every home

Patients get a 24/7 assistant. You get the data and decisions back, automatically.

On-demand provider summaries

Whenever you need to check in — a clean, accurate, one-screen summary. No chart-diving.

What it means for you

Better outcomes. Fewer readmissions. Zero manual effort.

Six ways AshvinDuo™ + KNOAH changes what comes after discharge.

A Continuous tracking

See every patient, everywhere — automatically.

From the moment they leave your ED, ward, or OR, you keep eyes on them — wherever they land. SNF, ALF, SLF, home with family, home alone. One cohort, one screen, no manual outreach.

  • Tracks across SNF, ALF, SLF, and Home — automatically
  • Zero staff time. No callbacks. No call lists.
  • Replaces costly outreach agencies and manual programs
  • Real-time recovery visibility across the full continuum
Tuesday discharge cohort · Day 4–14 Live
MC

Margaret Coleman

SNF Pinewood Skilled Nursing
Day 8
Recovering
RJ

Ronald Jenkins

Home with daughter (caregiver)
Day 5
BP rising
DT

Diana Torres

ALF Sunrise Assisted Living
Day 4
Stable
AB

Albert Brooks

SLF Heritage Senior Living
Day 11
On track
B Proactive alerts

Your rules. Watched 24/7. Acted on instantly.

Your clinical team writes the rules in plain language. AshvinDuo™ + KNOAH watches every patient against them — and pings the right person the moment anything matters. No more 14-day check-ins that arrive 10 days too late.

  • Write rules in plain English — no developer needed
  • Watched against every patient, every signal, every day
  • Alerts routed to the right care team automatically
  • Intervene days earlier — before the bounce-back
Rules · CHF cohort Add rule
If BP > 150/95 for 48 hours, alert the discharge planner.
Triggered 3× this week · 100% intervened
If weight doesn't drop 4 lbs in 7 days, adjust diuretic and notify cardiology.
Triggered 7× this month · avg time-to-action 11 min
If patient reports worsening shortness of breath, notify on-call team within 15 min.
Always-on · routes to pager
C Intelligent auto-adjust

The care plan adjusts itself — gently, intelligently, in plain language.

When a rule fires, the platform doesn't just alert your team. It guides the patient, the family, and the caregiver — in plain language they can act on — and keeps adjusting as the patient progresses. Adherence becomes the default, not the exception.

  • Adjustments delivered directly to patient, family, and caregiver
  • Dynamic plans that evolve with recovery
  • Plain-language guidance — no clinician translation required
  • Adherence happens without hospital staff involvement
Mr. Jenkins · CHF · auto-adjustments this week
Mon · Day 2
Reminded daughter to log daily weight at 8 AM.
Wed · Day 4
Detected +1.8 lb in 24h. Added 1 g sodium restriction guidance.
Thu · Day 5
BP trending up. Coached patient on furosemide timing and notified cardiology.
Fri · Day 6
Cardiology adjusted dose. Patient guided through new schedule.
D On-demand summaries

One screen. Everything you need. Nothing you don't.

Whenever a provider wants to check in — between rounds, before a phone call, during a follow-up — a clean, AI-generated patient summary is ready. Only what's relevant. No chart-diving. No outreach. No staff lift.

  • Concise, accurate, AI-generated — built fresh each request
  • Only the data points that matter to this provider, this patient
  • No chart-diving. No nurse calls to the SNF.
  • Cite-backed to the underlying source for verification
KNOAH · Patient summary
Margaret Coleman · 78 · CHF + post-op
Generated · 2s ago

Day 8 of 24 at Pinewood SNF. PT progressing well — completed 5/5 sessions this week. Weight stable at 142 lbs. BP averaged 128/78.

No alerts triggered. Family engaged daily via the companion app. Projected discharge to home: Day 22.

128/78
BP avg
142
Weight (lbs)
5/5
PT sessions
E Readmissions & penalties

Catch decline at Day 4 — not in the ED at Day 18.

Early detection means early intervention. Early intervention means fewer 30-day readmissions. Fewer readmissions means lower HRRP penalties, higher star ratings, and a hospital reputation that holds.

  • Earlier detection across every facility type
  • Earlier intervention, before the ED becomes the answer
  • Lower 30-day readmits, lower HRRP penalty exposure
  • Higher star ratings, stronger payer relationships
−38%
Average reduction in 30-day readmissions across the first three deployed cohorts.
30-day readmission rate ▼ 38% YoY
Last year (baseline) With AshvinDuo™ + KNOAH
F Patient & family satisfaction

The discharge experience that defines you.

Patients feel supported, every day, from the moment they leave. Families feel informed without lifting a phone. Your hospital delivers continuity of care that extends beyond your walls — and the survey scores reflect it.

  • Patients feel supported through their entire recovery
  • Families feel informed — without calling the floor
  • Continuity of care, beyond your physical walls
  • HCAHPS & post-discharge satisfaction scores climb
94%
CSAT
Felt supported96%
Families informed92%
Recommend hospital89%
HCAHPS lift+11 pts
Hospitals deserve better

Imagine a hospital that ends discharge with confidence.

Not someday. Not in five years. The day after you go live.

Providers walk out at 6 PM knowing every patient is being watched.

Not by hope. Not by a clipboard. By a system that doesn't sleep, doesn't forget, and doesn't miss the signals that matter.

The blind spot, gone.

Readmissions stop dragging your reputation.

Star ratings climb. HRRP exposure shrinks. Payers notice.

You stop paying agencies millions.

The outreach program retires. The budget moves to care.

Patients recover better.

Because someone is paying attention every day they're not in your building.

Families feel cared for.

Updates land in their hand. The phone calls stop being one-way.

Leaders lead, again.

Not firefighting M&Ms and audits. Building the hospital you came here to build.

What hospital leaders are saying

The shift, in their words.

"
For the first time in my career, I can answer "how's our cohort doing?" in seconds, not weeks. We catch deterioration before the ED does. That changes everything about how we discharge.
DK
Dr. Daniel Kapoor
Chief Medical Officer · 600-bed academic medical center
Questions from hospital leaders

Frequently asked questions

How does SolidHealth.AI help hospitals reduce 30-day readmissions?

AshvinDuo™ gives your care teams continuous visibility into every discharged patient — across skilled nursing, assisted living, senior living, and home. KNOAH, our agentic AI, watches each patient against the rules your clinicians set and raises a proactive alert the moment something matters, often days before an emergency-department visit. That early warning lets teams intervene in time to prevent avoidable readmissions and the CMS HRRP penalties tied to them.

What's the difference between AshvinDuo™ and KNOAH?

KNOAH is SolidHealth.AI's agentic AI engine. AshvinDuo™ is the acute-care product it powers — the post-discharge monitoring and care-coordination layer your teams actually see and use. KNOAH continuously interprets each patient's data, generates plain-language patient summaries on demand, and proposes care-plan adjustments; AshvinDuo™ brings that into one screen for discharge planning, care coordination, and population health.

Which post-acute settings does AshvinDuo™ monitor?

The full post-discharge journey — skilled nursing facilities (SNFs), assisted living facilities (ALFs), senior living facilities (SLFs), and the patient's home. Instead of losing sight of patients the moment they leave your doors, you keep one continuous view across every setting.

Does AshvinDuo™ work with our existing EHR?

Yes. AshvinDuo™ connects with Epic and Cerner over HL7 FHIR, so it fits into the systems your hospital already runs rather than replacing them.

How quickly can we see how a discharged cohort is doing?

In seconds. AshvinDuo™ updates continuously, so instead of waiting weeks for manual chart pulls or readmission reports, your team can answer “how is our discharged cohort doing right now?” on demand.

Is patient data handled securely?

Yes. AshvinDuo™ is HIPAA compliant and SOC 2 ready, and exchanges patient data through standards-based HL7 FHIR interfaces.

HIPAA-Compliant · Enterprise-Grade Security
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