Hospital Partner Brief
AfterNest is a proposed hospital-linked, non-clinical recovery support service for vulnerable patients leaving the hospital without enough practical help at home. A trained Recovery Navigator would support transportation, appointment logistics, technology, language navigation, caregiver coordination, and community-resource needs for approximately the first 30 days after discharge.
Why this is different from reminders or referral lists
Reminders tell patients what to do. AfterNest is designed to help them actually do it. A referral is not considered complete simply because a phone number or resource was provided. The Navigator helps move each approved practical need toward a clear outcome.
Proposed pilot population
The final presentation identifies older adults, people living alone, lower-income patients, and patients facing language barriers as priority groups for the proposed pilot. The broader paper also highlights patients without nearby caregivers and people facing transportation or technology barriers.
Patient workflow
- Refer. A hospital team member identifies an eligible patient and offers the voluntary program before discharge.
- Match. The patient is paired with a Recovery Navigator based on needs, language, and availability.
- Non-Clinical Recovery Support Plan. Approved practical barriers become specific next steps for approximately the first 30 days after discharge.
- Resolve. The Navigator works through practical tasks while clinical questions return to the approved care-team pathway.
- Graduate. Support closes when barriers are resolved, handed off, declined, or escalated.
Division of responsibility
Hospital partner
Define eligibility, introduce the optional program, establish the referral and consent workflow, retain clinical responsibility, and provide a clear pathway for clinical escalation.
AfterNest
Recruit and train Recovery Navigators, coordinate non-clinical support, maintain the approved practical-support scope, track pilot outcomes, and report agreed process measures.
What AfterNest would not do
- Diagnose, treat, advise on medications, or interpret symptoms
- Replace doctors, nurses, social workers, case management, home health, or qualified healthcare interpreters
- Provide unrestricted EHR access to Navigators
- Represent a practical process metric as proof of a clinical outcome
- Guarantee lower readmission, fewer complications, or any other clinical result
Six-month pilot
The final project plan calls for a soft launch at one hospital with a limited number of patients for six months. During that period, the team would track KPIs and feedback, identify pain points and bottlenecks, refine SOPs, and address major issues before considering a larger launch.
Funding structure
Outside funding could come from grants, community foundations, hospital partnerships, fundraising, sponsorships, and individual donations. The goal is to avoid dependence on a single hospital or donor.
Recommended next step
Conduct a workflow-design discussion with the prospective hospital partner to define eligibility, referral procedures, practical-support scope, escalation, privacy, training, measurement, and the operating requirements for a limited six-month pilot.
Academic prototype for partner discussion. UCSF Health is the team’s preferred potential partner in the final presentation and project plan; no partnership, endorsement, sponsorship, or clinical integration is confirmed. Real implementation would require partner, legal, privacy, insurance, clinical, and regulatory review.