Abstract: Systems and methods are disclosed for improving healthcare outcomes, such as following discharge of a patient following discharge from a hospital or other facility. In some embodiments, a first computer system of a first entity, detects discharge of a patient from a second entity based on activities of the patient and in response transmits, to an electronic device of a second entity, a request for discharge information of the patient. One or more follow-up activities are automatically scheduled for the patient and participation of the patient in the activities is verified by the first computer system. Follow-up activities may include a visit to a primary care physician (PCP), an in-person phone call, automated phone call, and other activities. One or more escalation actions may be taken based on results of these activities or failure of the patient to take part in these activities.