PAs Transform Post-Discharge Care, Reduce Readmissions with the Support of AI

“As technology evolves and becomes more integrated within healthcare, we’ll be able to better measure outcomes, improve patient experiences, and truly put the individual patient at the center of care.”

March 20, 2025

By Dave Andrews

Advancements in technology continue to enhance the way we live, making life easier, safer, and more efficient. In healthcare, tech innovations are especially impactful, helping medical providers deliver better care and improve patient outcomes.

However, despite rapid progress, there remain significant gaps in healthcare, particularly in the post-discharge phase, where patients often fall through the cracks.

One promising solution is the integration of artificial intelligence (AI) to provide more proactive post-discharge care. Carrie Hodge, PA-C, co-founder and CEO of Dimer Health, believes that AI can play a critical role in helping patients avoid the common setbacks that often occur after they leave the hospital.

Before founding Dimer Health, Hodge spent over 17 years in emergency medicine, where she repeatedly saw patients discharged only to return to the emergency department soon after.

“All too often, patients who had been discharged would be readmitted just days or weeks later with exacerbated symptoms, new infections, or other preventable complications,” Hodge said.

She went on to explain the increasingly common scenario of patients in the U.S. waiting several weeks before their first follow-up appointment after hospital discharge. This delay can be especially dangerous for patients with complex or serious conditions, she said.

“In my experience, and based on research at Dimer Health, if you can reach a patient within the first 72 hours after discharge, you can dramatically improve their chances of recovery,” Hodge said. “But beyond that window, the impact of follow-up care diminishes significantly.”

Revolutionizing Patient Care Beyond the Hospital
Determined to close these critical gaps in post-discharge care, Hodge focused on creating a model that would provide more consistent, proactive care solutions. In 2022, she teamed up with a former ED colleague of hers, Gidon Coussin, DMSc, PA-C, and Sarig Reichert, an entrepreneur and product specialist, to develop a technology-driven post-discharge model of care.

Together, after several months of business planning and product development, they launched Dimer Health with a clinical platform designed to provide personalized, real-time, dynamic support for patients during the critical time after a hospital discharge.

Dimer Health’s AI-powered platform continuously monitors patients after they leave the hospital, analyzing both health records and real-time data collected through virtual check-ins, text messages, phone calls, and provider visits. The technology assigns a risk score based on the patient’s condition, social determinants of health, and other personal parameters; generates tailored care recommendations for providers; and ensures follow-up appointments are scheduled when needed.

Bridging this gap between hospital discharge and recovery prevents avoidable complications, reduces hospital readmissions, and ensures patients receive the right care at the right time.

AI as a ‘Co-Pilot’ for Providers
While AI plays a central role in Dimer Health’s model, Reichert emphasizes that it is not intended to replace the clinician, but rather to enhance their ability to be efficient and proactive. The technology can aid in creating customized and highly personalized care plans and proactively identifying and addressing potential risks.

“I think of this technology as the provider’s co-pilot,” Reichert said. “It’s designed to save providers time by offering actionable insights and recommendations, supporting them throughout the decision-making process.”

First-Hand Struggles of Post-Discharge Recovery
The founders of Dimer Health understand exactly how challenging the recovery process can be after leaving the hospital. Coussin, who has over 10 years of experience in emergency medicine, had his own eye-opening moment after a serious skiing accident. He was hospitalized for several days, and despite his medical background, he found himself struggling during the post-discharge period.

“Even though I know medicine and had access to all the resources, I was so out of it after my hospital stay that I accidentally took my pain medication incorrectly for three days,” Coussin said. “Fortunately, I didn’t suffer any lasting effects, but it made me realize even more acutely how vulnerable patients are once they leave the hospital.”

Coussin’s experience only reinforced his belief that the post-discharge phase of care needs improvement. He is confident that the care model developed at Dimer Health will have a significant impact on healthcare, ensuring that patients receive the support they need at every stage of recovery.

“I truly believe this is a game changer and will one day become the standard of care,” Coussin said. “Just as the various care services are coordinated within the hospital, that should continue once the patient leaves. There should never be a point when the responsibility falls entirely on the patient to identify a decline in their condition or to figure out what comes next.”

Achieving Measurable Results
Hodge, Coussin, and Reichert created Dimer Health with high hopes of improving outcomes, and the results thus far have exceeded even their own lofty expectations. Currently serving patients in parts of New York, New Jersey, and Florida, Dimer has already reported a 67% reduction in hospital readmissions among its cohort of patients compared to patients with similar conditions served by other providers.

Patient satisfaction has also been overwhelmingly positive, according to Reichert. “We’re continuously monitoring our [Net Promoter Score] among our patients and it’s typically around 95% [satisfied], which is very, very high, especially within the healthcare industry,” Reichert said.

Dimer’s co-founders are pleased with the early results, which they view as further validation of an industry in urgent need of more proactive, technology-driven, post-discharge care. However, they recognize that broader change is still needed to fully realize a patient-centered, value-based healthcare system.

“Ultimately, we need a shared unit of value across healthcare that defines success,” Hodge said. “As technology evolves and becomes more integrated within healthcare — leveraging AI, real-time data, and LLMs — we’ll be able to better measure outcomes, improve patient experiences and truly put the individual patient at the center of care. I don’t think we’re far from that reality.”

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