For health systems and universities
Your panel: the patients your clinicians are responsible for. Readmission penalties: Medicare pays hospitals less when too many patients bounce back within 30 days; about 78% of hospitals are penalized.3
Carrie
Your front desk builds patient relationships. Carrie keeps them going, coordinating what your team can’t get to, whether its scheduling, refills, triage, escalations, or follow-ups.
Pre-Visit/Procedure Preparation.
Post-Visit/Procedure Follow-up.
Retain and Re-engage.
Complete Programs, adjusted to your system, ready to run.
Each Program ships whole: the calling schedule, the questions, the adherence logic, and the persistence to actually reach people.
Carrie initiates calls, leaves voicemails, retries at hours that work, and calls back when asked. The cadence tightens when risk rises and loosens as patients stabilize. Between every scheduled call, patients can call her at any hour with any question. She’ll route to the care team when they’re needed.
With considerations to multimorbid patients, Programs are built to be aware of each other. Multiple Programs run all at once for the same patient, and each will share what it learns with the others.
The cadence
Daily calls the first week home, when readmission risk peaks; tapers as the patient stabilizes; any warning sign pulls it back to daily.
On every call
Breathing at rest, lying flat, and on stairs; swelling in legs or belly; sudden weight gain (2 to 3 pounds overnight is fluid, and fluid is the signal); dizziness.
Keeps on track
The diuretic (water pill) and the rest of the med list, refills actually picked up, salt and fluid limits, the daily weigh-in.
The cadence
Weekly while finding the right dose, monthly once controlled; a run of high readings tightens it.
On every call
Home cuff readings and their trend, dizziness or lightheadedness (often a dosing signal), headaches or vision changes.
Keeps on track
Blood-pressure meds and refills, the home-cuff habit and technique, salt.
The cadence
Set by how controlled the patient is; new insulin starts get close, frequent attention.
On every call
Glucose patterns, low-sugar episodes (shaky, sweaty, confused), foot sores that won’t heal, vision changes.
Keeps on track
Insulin and oral meds, refills, A1c lab draws on schedule, eating patterns that move the numbers.
The cadence
Monthly through stable stretches, tightening around lab draws and after any decline.
On every call
Swelling, changes in urination, blood-pressure readings, and new medications that stress the kidneys (common painkillers like ibuprofen top the list).
Keeps on track
Blood-pressure meds, the kidney diet (potassium and phosphorus limits), labs on schedule.
The cadence
Steady through stable months, daily through and after a flare.
On every call
Breathlessness against the patient’s own baseline, rescue-inhaler use (reaching for it more often is the early warning), cough and sputum changes.
Keeps on track
Daily inhalers and technique, refills, oxygen where prescribed, quit-smoking support when the patient wants it.
The cadence
Timed to the infusion cycle, calling on the days side effects usually peak, through the whole course of treatment.
On every call
Fever (after chemo a fever can be an emergency, and she treats it like one), nausea and whether anything stays down, mouth sores, numbness or tingling in hands and feet.
Keeps on track
Anti-nausea meds taken on schedule (they work best taken early), hydration, readiness for the next infusion.
Carrie never diagnoses, prescribes, or places orders; clinical judgment stays with the care team.
A modeled 5,000-patient cohort: published transition-of-care programs reduce readmissions in the 20 to 40% range.7 In scoping, we rebuild it with your numbers.
5,000
annual heart-failure discharges
22%8
30-day readmission rate
1,100
readmissions a year
20 to 40%7
published program range
220 to 440
modeled readmissions avoided a year, and that much penalty exposure closed
³ CMS Hospital Readmissions Reduction Program, FY2026. ⁷ Modeled assumption drawn from published transition-program ranges (20 to 40%); not a Carrie outcome claim. ⁸ Modeled baseline. Published 30-day readmission rates for Medicare heart-failure patients commonly run 20 to 25%; the model assumes 22%. Not a Carrie outcome claim.