For health systems & universities
Carrie follows up with discharged and chronic-care patients between visits, so problems surface before they turn into readmissions. About 78% of hospitals pay a readmission penalty.3
After discharge
Four hand-offs follow every heart failure discharge, and each one depends on someone confirming it happened. Switch to “With Carrie” to see them closed.
Example · Heart failure discharge
A patient goes home after a heart failure admission.
0/4hand-offs confirmed
Example scenario.
Chronic care Programs
Each Program ships whole: the calling schedule, the questions, and what Carrie does with each answer. Between scheduled calls, patients can call Carrie at any hour, and Programs share what they learn when a patient lives with more than one condition.
Daily calls the first week home, when readmission risk peaks; tapers as the patient stabilizes; any warning sign pulls it back to daily.
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.
The diuretic (water pill) and the rest of the med list, refills actually picked up, salt and fluid limits, the daily weigh-in.
Weekly while finding the right dose, monthly once controlled; a run of high readings tightens it.
Home cuff readings and their trend, dizziness or lightheadedness (often a dosing signal), headaches or vision changes.
Blood-pressure meds and refills, the home-cuff habit and technique, salt.
Set by how controlled the patient is; new insulin starts get close, frequent attention.
Glucose patterns, low-sugar episodes (shaky, sweaty, confused), foot sores that won’t heal, vision changes.
Insulin and oral meds, refills, A1c lab draws on schedule, eating patterns that move the numbers.
Monthly through stable stretches, tightening around lab draws and after any decline.
Swelling, changes in urination, blood-pressure readings, and new medications that stress the kidneys (common painkillers like ibuprofen top the list).
Blood-pressure meds, the kidney diet (potassium and phosphorus limits), labs on schedule.
Steady through stable months, daily through and after a flare.
Breathlessness against the patient’s own baseline, rescue-inhaler use (reaching for it more often is the early warning), cough and sputum changes.
Daily inhalers and technique, refills, oxygen where prescribed, quit-smoking support when the patient wants it.
Timed to the infusion cycle, calling on the days side effects usually peak, through the whole course of treatment.
Fever (after chemo a fever can be an emergency, and Carrie treats it like one), nausea and whether anything stays down, mouth sores, numbness or tingling in hands and feet.
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.
Hear Carrie
Transcript · select a line to jump there
A missed refill caught between visits, not at the next admission.
Carrie asks the questions the Program sets, notices what matters (here, an anti-nausea medication that ran out), and gets it to the care team right after the call. The transcript and summary go back to the patient’s record.
Demo call with a simulated patient.
The math
A modeled 5,000-patient cohort, using published transition-of-care results. 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
20–40%7
published program range
220–440
readmissions avoided a year, and that much penalty exposure closed
for your health system?Start with a scoping call. We’ll rebuild the readmission math with your numbers.
Book a scoping callNames and scenarios on this page are illustrative examples. 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.