Workflow is usable
Referrals are appropriate, first contact is timely, barriers move toward resolution, and partner burden is acceptable.
Illustrative prototype data ยท not real patient outcomes
Measure whether the support model actually executes.
The proposed scorecard separates activity from completion. A referral sent is not a barrier resolved. A reminder delivered is not transportation arranged. The six-month pilot should show where practical work closes, where it stalls, and where it needs escalation or redesign.
Operational view
What a hospital partner could review during the pilot.
These demo charts use seeded prototype cases only. A live pilot would require partner-approved metric definitions, privacy controls, and reporting rules before any patient-level or aggregate data are shared.
Practical barriers in the demo cohort
Count of identified support needs across seeded and locally created demo cases.
Task resolution status
Resolution status across all practical tasks in the Non-Clinical Recovery Support Plans.
Pilot scorecard
Five questions the six-month pilot should answer.
The first pilot is meant to test the operating model, integration burden, workforce model, and practical-resolution process before making claims about clinical effectiveness.
Question
Measures
Decision it informs
Can we reach the right patients?
Referral volume, opt-in, first-contact time
Whether eligibility and the warm-handoff workflow are usable.
Can we resolve practical barriers?
Resolution rate, time to resolution, overdue tasks
Whether the operating model creates real follow-through.
Can we stay inside scope?
Escalations, handoffs, boundary incidents
Whether training and clinical escalation are safe and clear.
Does the service fit the workflow?
Patient and healthcare worker feedback
Whether the service adds value without creating excessive burden.
Can the model be sustained?
Navigator workload, retention, cost per patient
Whether staffing and funding assumptions are realistic.
Reporting cadence
Make course correction part of the pilot design.
Weekly
Operational review
Active caseload, overdue practical tasks, escalation volume, Navigator capacity, resource gaps, and referral issues.
Monthly
Partner scorecard
Enrollment, first-contact performance, barriers by category, resolution rates, handoffs, patient experience, and workflow changes.
Month 3
Mid-pilot review
Formal checkpoint on eligibility, staffing, supervision, privacy boundaries, resource availability, technology, and partner burden.
Month 6
Pilot closeout recommendation
Summarize feasibility, process outcomes, feedback, costs, risks, lessons learned, and the issues that must be addressed before any larger launch.
Decision discipline
Define success before the pilot starts.
The partner and AfterNest should agree in advance on the evidence needed to continue, redesign, narrow, or stop the program.
Value exists but friction is high
Eligibility, staffing, training, resource access, technology, or escalation needs material redesign.
Only some use cases work
The model performs better for a specific population, barrier category, or service line.
Risk or burden exceeds value
Clinical-boundary failures, low engagement, unresolved operational risk, or poor feasibility would argue against expansion.
Evidence discipline
Do not overclaim what a pilot proves.
The proposal identifies patient and healthcare worker feedback and lower post-discharge issues or complications as desired measures. This prototype directly demonstrates process measures; any claim about clinical outcomes would require an appropriate study design and partner-approved analysis.