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Live in productionसेतु
Setu: transitions of care agent
Hindi for “bridge”
An enterprise workflow agent for discharge follow-up, transition tasks, and accountable handoffs.
Setu is a developed transitions of care agent that organizes authorized discharge and follow-up data into operational queues across existing enterprise systems.

Intended workflow
Transitions of care workflows, organized above existing enterprise data.
- Receive authorized discharge or transition signals
- Create accountable follow-up and outreach queues
- Track task status and unresolved handoffs for staff review
The deployment model is intentionally vendor-neutral. Data access, identity, security, auditability, human review, and any write-back will be defined with the enterprise before implementation.
Setu is live in production across three enterprise deployments and is delivered as a cloud-hosted service. Pricing is outcomes based, agreed with each organization against operational measures defined in the engagement. Inquiries go through the interest form on this page or to support@synodha.com.
- Setu TOC Agent
Prepares work queues, shows why each record appears, and routes incomplete records to an exception queue.
- Accountable human review
Named owners approve, escalate, or close every item. No outreach or change proceeds without it.
- Authorized enterprise data
APIs, governed feeds, a data warehouse, or an existing integration layer, defined with each organization.
- Systems of record
The EHR and enterprise systems remain the source of truth. Setu does not replace them.
Enterprise questions
What teams should know before evaluating Setu.
What does the Setu TOC Agent do after a discharge?
Setu turns an authorized discharge, referral or other transition signal into operational follow-up work. It matches the event to the correct patient, applies routing rules your organization defines, assigns the resulting task to an accountable role, and tracks handoffs that are still unresolved. Setu does not make patient-specific clinical judgments, determine coverage, or turn a queue item into billing evidence.
How does Setu build post-discharge follow-up queues from data we already have?
A deployment reads approved discharge and follow-up sources through the route your organization authorizes, which may be APIs, governed feeds, transition documents, a warehouse, a health information exchange, or an enterprise integration layer. Each item shows its source, timestamp, inclusion reason, required action and missing data. Duplicates, conflicts, late feeds and uncertain matches go to an exception queue rather than into the working list.
Can Setu work with discharge data from different EHRs?
Yes, Setu is EHR-agnostic and runs as a cloud-hosted service. Each source still needs its own field mapping, provenance, patient matching, refresh expectations, validation, access controls, failure handling, and an explicit read-only or write-back model, agreed with your team before implementation. Synodha claims no endorsement by any EHR vendor.
What controls should govern a Setu deployment?
Require authorized sources, patient-matching tests, visible provenance and timestamps, role-based access, approved communication channels, human approval points, an accountable owner per queue, an exception queue, audit events, a downtime procedure, and representative validation before go-live. Prohibited uses should be written down too, including autonomous clinical decisions and unsupported billing actions.
Program context: CMS Transitional Care Management Services. Synodha's product scope remains separate from CMS coverage and billing requirements. If you are scoping more than this one workflow, see how this workflow fits a payment-model transition, or what all three agents have in common.
Read Post-discharge follow-up automation: a TOC controls checklist
Setu is live in production across three enterprise deployments. No EHR vendor endorsement, regulatory compliance certification, billing accuracy, reimbursement eligibility, autonomous clinical decision-making, or clinical outcome improvement is claimed.