Consistent human support
Recovering older adults who may benefit from a reliable person helping them work through practical next steps.
How AfterNest works
Practical support between the discharge plan and daily life at home.
AfterNest is a hospital-linked, non-clinical support service that would assign a trained Recovery Navigator for approximately the first 30 days after discharge. The Navigator helps patients work through transportation, technology, language navigation, appointment logistics, caregiver coordination, and community-resource barriers.
Hospital referral + opt-inApproximately 30 daysPhone, video, or in-person support as approved
Illustrative concept imagery for the proposed pilot.
Who the pilot is for
Patients who are medically ready to leave but may not have enough practical support at home.
The proposed pilot would focus on a narrow population rather than every discharge. The final presentation identifies four priority groups.
Limited support at home
Patients without a household member or nearby caregiver available to help manage practical recovery tasks.
Limited access to paid support
Patients who may have fewer options for transportation, home support, technology help, or other paid post-discharge services.
Non-clinical navigation
Patients who prefer non-clinical support in another language or need help navigating resources. Clinical interpretation remains with qualified health-system services.
Non-Clinical Recovery Support Plan
Turn identified barriers into practical next steps.
The referral is intentionally limited to information needed for non-clinical support. The academic prototype does not request diagnoses, medication lists, symptoms, lab values, or clinical notes.
T
TransportationIs a reliable ride available for the next appointment or required service?
D
Digital accessCan the patient use the portal, device, scheduling, or video-visit tools needed for follow-up?
L
Language navigationWhat language is preferred for non-clinical logistics and resource navigation?
S
Support at homeIs caregiver help, food, basic-needs support, or another practical resource missing?
Examples of follow-through
What the Navigator can actually help move forward.
The role is deliberately practical. Support may happen by phone, video, or in person depending on the need and the partner-approved pilot procedures.
Transportation
Coordinate the ride
Find an appropriate option, confirm logistics, and verify that transportation is actually arranged.
Technology
Practice the tool
Help the patient use portals, video visits, appointment details, scheduling, and basic digital workflows.
Navigation
Clarify the next step
Help organize non-clinical logistics and route clinical questions back to the approved healthcare contact.
Illustrative concept imagery, not photographs of an operating AfterNest program.
The patient journey
One clear handoff. One Navigator. Visible follow-through.
Support is expected to last approximately the first 30 days after discharge, with closure based on whether priority practical barriers have a clear outcome.
01
Refer
A hospital team member identifies an eligible patient and offers the voluntary program.
02
Match
The patient is paired with a Recovery Navigator based on needs, language, and availability.
03
Resolve
The Navigator works through approved practical barriers and tracks each next step.
04
Graduate
Support closes when barriers are resolved, handed off, declined, or escalated.
Clear clinical boundary
The hospital owns the medicine. AfterNest supports the practical follow-through.
Recovery Navigators do not diagnose, treat, interpret symptoms, advise on medications, replace doctors, nurses, social workers, or home health, or provide emergency response. Clinical concerns return to the partner-approved healthcare pathway.