For many individuals, leaving the hospital marks the beginning of a complex recovery process filled with new symptoms, medication questions, and follow-up scheduling hurdles. To bridge this critical gap, Bergen New Bridge Medical Center and Dimer Health have partnered to deliver dedicated clinical oversight during the pivotal 30-day post-discharge period.
Between January and October 2026, the program provided tailored post-discharge care to 680 patients from Bergen New Bridge Medical Center, a nonprofit safety-net hospital based in Paramus. The initiative successfully identified unmet care needs in nearly 1 in 4 patients (23%), connecting them directly to essential medical services, behavioral health treatment, and ongoing clinical support.
For vulnerable patients facing financial, language, or social barriers, the transition home after a hospital stay can lead to preventable readmissions if care gaps are left unaddressed. Through Dimer Health’s platform, patients were supported by “Transitionists™”—licensed clinicians specializing in post-discharge care—alongside AI-powered technology that handles routine inquiries, provides personalized guidance, and flags emerging clinical concerns.
Data from the 10-month program highlighted key outcomes for the 154 patients identified with care gaps:
- Targeted Care Coordination: While 77% of enrolled patients were monitored and treated during their 30-day window without needing external referrals, 23% required additional interventions.
- Addressing Diverse Needs: Among patients requiring extra support, 60% needed specialist referrals, 25% required primary care assistance (such as securing a doctor or accessing charity care), and 38% needed support with services including lab work, imaging, Medicaid enrollment, home health, or substance use treatment. One in five of these patients faced two or more overlapping needs.
- High Referral Success: 89% of patients with identified care gaps were successfully referred or scheduled for continued care, including 61% with confirmed appointments or established care.
- Patient Satisfaction: Patients rated the program 4.9 out of 5 stars, giving it a Net Promoter Score (NPS) of 91.
“Patients don’t stop needing care when they leave the hospital, but too often, that’s when they lose access to it,” Caroline Hodge, co-founder of Dimer Health, said. “Our Transitionists™ take responsibility for those next 30 days. They’re there to answer questions, recognize when something isn’t right, and step in before a small concern becomes a bigger problem.”
Bergen New Bridge Medical Center—the largest hospital and licensed nursing home in New Jersey—plans to expand the Dimer Health post-discharge program to additional units following these positive early results.
“We want our patients to feel supported and confident about their recovery when they go home,” Deborah Visconi, President and CEO of Bergen New Bridge Medical Center, said. “With Dimer Health, we can stay connected, answer questions, and help our patients get the care and support they need to keep getting better.”
Across its broader health system implementations, Dimer Health’s hybrid care model—combining 24/7 access to Transitionists™ with AI monitoring—has served more than 35,000 patients, reducing overall 30-day hospital readmissions by 42% and shortening return stays by an average of two nights.
