Healthcare Care Management Workflow Office365

We have a need to automate steps in care planning as a patient transitions from a hospital to a nursing home and to home. We would like to use Office365, Microsoft Teams for Healthcare (including add-ons, Lists, Tasks, etc) and Power Apps and Outlook in it's fullest functionality without having to subscribe to additional features. This is a prototype short term workflow until we incorporate with our clinical data repository/back-end which would be phase 2. See the workflow attached - please only reach-out after examining the workflow and proposing a solution design. Thanks!