MayaRED: Your Discharge Experts
Safer transitions. Stronger recoveries.
MayaRED delivers all 13 elements of RED and confirms patients understand their plan, backed by 30 days of real clinical follow-up. The proven protocol, without the staffing problem.
Patients leave thinking they understand. Most don't.
Patients leave with complex instructions and changing medications, and most overestimate how well they understand them. Those hidden gaps become readmissions and avoidable ED visits.
Medicare patients readmitted within 30 days
Older patients who said they understood why they were hospitalized, vs. those who could actually describe their diagnosis
Horwitz et al., JAMA Intern Med 2013How often discharged patients recognized their own gaps in understanding
Engel et al., Ann Emerg Med 2009There's already a proven fix for this.
RED (Re-Engineered Discharge) is a structured, evidence-based discharge protocol developed with Boston University researchers: a 13-step process designed to close the exact gaps that drive readmissions. Every element is confirmed using teach-back, where patients explain the plan in their own words, so understanding is verified, not assumed.
- The same 13 steps to every patient, every shift
- Confirms understanding with teach-back, rather than assuming it
- Translates discharge instructions into plain language
- Reviews every medication, old and new
- Confirms follow-up appointments, tests and labs
- Teaches the warning signs and when to call for help
Adopted by the National Quality Forum as one of 30 Safe Practices.
fewer readmissions
increase in patient satisfaction
modeled savings per 1,000 patients
RED randomized trial (Jack et al., Ann Intern Med 2009), supported by a 2021 meta-analysis of 60+ RCTs and 16,000+ patients. Savings are a modeled estimate and vary by payer mix and patient population.
Manual RED runs entirely on staff time.
Every one of the 13 steps falls to case management and nursing, for every patient, every discharge, every shift. That is why a protocol this well proven is still delivered inconsistently, or not at all.
Staff time
- Consumes clinical hours on every discharge
- Pulls skilled nurses away from the bedside
- Requires continuous training and oversight
Patient comprehension
- Paper packets fail to ensure comprehension at home
- Language gaps create post-discharge risk
- Patients struggle with complex medication routines
Process consistency
- Delivery quality varies between teams and shifts
- High clinical load leads to rushed or skipped steps
- Hard to standardize manually without technology
Maya guides patients through all 13 elements of RED and confirms understanding.
Maya guides
Every patient gets the full RED protocol in plain language, with teach-back on each element.
Our care team follows
Thirty days of clinical follow-up, with accountability and escalation when something needs attention.
Your team gains
Fewer readmissions, a better patient experience and less burden on staff.
Your team makes the introduction at discharge. We carry it from there and create a comprehension report for every patient.
Engaged from discharge to day 30.
Every patient receives structured, timely touch points, from discharge-day education through a full month of clinical follow-up.
- DAY 0DischargeGuided RED education with teach-back begins at discharge.
- DAY 1–2First contactPatient contacted within 2 business days.
- DAY 7Clinician visitFollow-up clinician visit completed within 7 days.
- WEEKS 2–3Ongoing supportCheck-ins, medication reminders and red-flag monitoring.
- DAY 30CompleteClose the loop and capture the patient experience.
Maya turns discharge papers into a guided experience.
Patients use it at their own pace: listen, pause, skip ahead, go back, replay a section, switch to text, or stop and return anytime.
- Maya explains the plan in plain language
- Patients move section by section
- Listen or read, and ask Maya questions
- Walks through each medication, old and new
MayaRED is already delivering results.
Fewer 30-day readmissions for heart failure patients vs. a matched control group, at Spring Valley Hospital (UHS)
Of patients preferred Maya for discharge education (average age 69)
"It was easier to understand than the nurses and doctors."Spring Valley Hospital patient
Cohort data presented at the American Heart Association 2024 conference. Partnership renewed and expanded.
Built with the people who created RED, on a platform that already runs care at scale.
The source
Built with Dr. Brian Jack and the Boston University faculty who created RED.
The gold standard
RED is a National Quality Forum Safe Practice and a Peter Drucker Award winner.
Proven at scale
The Maya platform supports nephrology partnerships across nine states, covering 300,000+ patients.
Secure
Encrypted and HIPAA compliant, with a signed Business Associate Agreement.
We do the heavy lifting. Your team makes the introduction.
No fee to your health system.
You provide
- One point of contact
- Discharge notification
- EHR access for our medical assistants
- Staff who introduce MayaRED at discharge
MayaMD provides
- The Maya platform, no app needed
- Medical assistants, nurse practitioners and physicians
- Connected home monitoring devices
- Patient outreach and consent support
- Documentation in your EHR
- Monthly outcome reporting
A partnership with results we review together.
Set up
You choose where to start: one unit or one condition. We align on the agreement and BAA, EHR access, discharge notifications and a short staff in-service. 4–6 weeks from signed agreement to go-live.
Go live
Patients enroll at discharge. Our team runs the full 30-day program, and you get monthly reports.
Review and expand
First results review at 90 days, then every six months: readmissions, satisfaction, enrollment and staff feedback. Then we decide together where to expand.
We agree on what success looks like before we go live.
A phased path. Go live quickly, then automate.
Manual handoff
Your team notifies us of discharges through a simple, secure process.
EHR access
Our medical assistants identify patients and document in your EHR.
EHR integration and automated alerts
A real-time discharge feed (ADT) notifies us automatically.
Start with EHR access on day one, then build to full integration.
MayaRED delivers something different for every leader in the room.
| Leader | What you get |
|---|---|
| CMO, Quality, Population Health | Fewer readmissions on the conditions CMS penalizes |
| Patient Experience | Patients who feel informed and cared for after they leave |
| Case Management | Follow-up handled by our team, with no change to your discharge process |
| CFO | Lower readmission penalty risk, with no fee to the health system |
| Compliance and Legal | A signed BAA and clear billing rules, with no payment tied to referral volume |
| IT | Start with basic EHR access; automated alerts can come later |
Frequently asked questions
How long does setup take?
4–6 weeks from signed agreement to go-live.
Which patients do you focus on?
You choose where to start. Most partners begin with heart failure or another CMS-penalized condition, then expand.
Will this add work for my staff?
Your team introduces MayaRED at discharge. We handle consent, onboarding, clinical visits and 30 days of support.
Is patient data secure?
Yes. Encrypted and HIPAA compliant, and we sign a BAA before go-live.
How is this different from AI calling or monitoring tools?
Those tools reach patients after they're home. MayaRED starts at discharge with the full RED protocol, confirms patients understand their plan, and follows up with real clinicians for 30 days.
If it's free to us, how do you get paid?
The program is funded by the transitional care MayaMD's team delivers and bills for, so there is no fee to your health system. If you already bill TCM, we set clear rules on which patients are ours so there is no overlap.
Let's take the next step together.
The scoping session is 60 minutes with Case Management, Quality and IT. You bring your readmission data; we bring a draft implementation plan and a sample agreement.
Meet the team.
Dr. Amit Kapoor, MD, MBA
CEONephrologist. Former Chief Nephrology Officer, Strive Health.
Dr. Vipindas Chengat, MD, FACP
Founder & ChairmanBoard-certified hospitalist and physician innovator.
Christian Habermann
Co-founder & CMO20+ years in sales and marketing leadership.