The moment a patient leaves the hospital, they step into a critical and often overlooked phase of care. Discharge papers in hand, they’re expected to manage medications, schedule follow-ups, and recognize warning signs — often without clear guidance or support. Because of that, too many fall through the cracks, leading to unnecessary complications, avoidable readmissions, and higher healthcare costs.
Caroline Hodge, CEO and co-founder of Dimer Health, has seen these failures firsthand. As a physician assistant in emergency medicine, she spent years treating patients who should never have ended up back in the hospital. Then, after battling cancer twice, she experienced the problem from the other side. Managing post-discharge care alone, even with her medical background, was overwhelming, and it fueled her determination to build a solution.
Dimer Health closes the post-discharge gap, combining clinical expertise with AI-driven technology to ensure patients receive the support they need when they need it. The impact is clear: a 68% reduction in hospital readmissions, better patient outcomes, and millions in healthcare cost savings.
“If only we had done this sooner for them, or if only they had gotten into their doctor a couple days earlier, they could have had this medication changed or started or this intervention done,” Hodge says. “If only someone had put eyes on them right after they had gotten home or answered these questions, they probably wouldn’t be here.”
The problem isn’t the care patients receive in the hospital, it’s what happens afterward. When you’re admitted, everything is decided for you. You know when to take your meds, when to eat, what’s next. Then suddenly, you’re home, and it’s all on you or your family to figure out.
Patients in this vulnerable state often struggle with medication errors, worsening symptoms, and delayed follow-ups. On average, it takes 29 days to see a primary care doctor after discharge. By then, small issues can spiral into major complications.
Dimer Health steps in immediately, connecting with patients within the first 72 hours, a critical window where intervention can change the trajectory of their recovery.
“If you can connect with a patient and see them within the first 72 hours after discharge, you can change the trajectory of their outcome,” Hodge says.
Dimer Health is building what Hodge calls a new specialty in medicine: transitional care. Much like hospitalists emerged decades ago to specialize in inpatient care, Dimer’s team of nurse practitioners, physician assistants, and doctors focus exclusively on helping patients recover after discharge.
“We grab your hand, like the hospitalist has one hand, we grab the other hand and we’ll hold you and hold your hand, we’re linked arms until we can hand you back off to your care team,” Hodge explains.
Dimer Health ensures that no patient is left navigating their recovery alone. Its model is built on real-time monitoring, proactive outreach, and AI-powered support.
The process starts with seamless doctor-to-doctor referrals, ensuring that patients are connected to transitional care before they even leave the hospital. AI prioritizes patient information so clinicians know exactly what needs attention. Automated documentation and clinical decision support free providers to focus on patients, not paperwork.
By integrating technology with hands-on care, Dimer Health not only improves patient outcomes but also reduces the administrative burden on clinicians. And the impact extends beyond individual patients. Preventing unnecessary readmissions eases hospital capacity, improves quality metrics, and drives significant cost savings.
“We’ve reduced readmissions by over 68% now, I think, is what we’re at,” Hodge says. “The average hospital admission is somewhere between $14,000 and $15,000. So, by avoiding that, there’s such a huge cost savings to the health system.”
Hospitals aren’t the only ones benefiting. Patients experience better, more personalized care, a shift back to the kind of doctor-patient relationships that existed before modern healthcare became transactional.
“We can bring healthcare back to that level of personalization that it was when the doctor was in your home,” Hodge says.
The goal is to move healthcare from a reactive system to a proactive one, where patients don’t wait until they’re seriously ill to seek help.
Hodge sees AI as a tool to improve, not replace, human-driven care. “We don’t measure patients per hour,” she says. “That’s not a metric that we use.” Instead, the focus is on ensuring patients receive the right care, at the right time, in a way that feels deeply personal.
Dimer Health’s model is already proving what’s possible, but Hodge believes there’s more to come. AI is still in its early days, and as it continues to evolve, so will healthcare.
There are now tools to personalize care at scale, to anticipate problems before they happen, rather than just reacting to them.
By shifting from crisis management to early intervention, the healthcare system can become more efficient, more effective, and, ultimately, more human.
Hospitals, insurers, and healthcare systems looking to reduce costs and improve patient outcomes should be paying attention. Dimer Health isn’t just an idea, it’s a working model.
Better care, fewer readmissions, and a healthcare system that finally works for patients — Caroline Hodge and Dimer Health are making it happen.
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