For Boulder Community Health

The discharge gap costs Boulder families — and BCH — more than anyone tracks.

co-op.care proposes a simple pilot: 10 families referred from BCH discharge. 90 days of coordinated care. Full structured outcome data — FHIR-compatible — back to your team at every milestone.

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3% CMS HRRP max penalty

~64% Agency caregiver turnover

<1mi From BCH campus

1 Boulder family already enrolled

The structural gap

What happens after the whiteboard clears

BCH delivers excellent acute care. The problem starts when the door closes behind the patient.

The gap

Discharge planners have ~10 minutes to arrange post-acute care from a narrow, pre-approved agency list
Home care agency turnover averages ~64%/year — the caregiver who knows the patient's routine is rarely the one who shows up next week
Medication non-adherence — the leading driver of preventable 30-day readmissions — goes unmonitored between agency visits
Medicare HRRP penalizes hospitals up to 3% of base DRG payments for excess readmissions across 7 high-risk conditions — including CHF, COPD, pneumonia, TKA, and THA

co-op.care's answer

Located less than 1 mile from BCH — same neighborhood, same streets, same community
One consistent W-2 caregiver per family. Not a revolving contractor pool — an owner who shows up because they have equity in the outcome
Sage AI monitors care gaps daily and flags concerns before they escalate — not after the 911 call
Physician oversight by our Chief Medical Officer — BCH hospitalist since 2008, physician-of-record for co-op.care's Colorado operations — provides care plan continuity and clinical attestation
FHIR-structured outcome data at 30/60/90 days — formatted for your quality reporting team, not buried in a caregiver's notes app

What BCH gets back — and when

Care data doesn't disappear into a home care agency's system. It loops back to you, structured and defensible.

Discharge referral

Your care management or discharge team refers a qualifying patient. ComfortCard created at bedside — full care history, active medications, advance directives, care goals — transfers in a single scan.

BCH action: 1 referral contact

Caregiver matched and assigned within 24 hours

CareOS matches a consistent, named, W-2 caregiver based on geography, skill set, and patient preferences. No rotating contractors — same person, every visit, from Day 1.

CareOS intelligent matching

Continuous monitoring by Sage AI

Sage monitors medication adherence, mobility trends, nutrition, and social isolation signals using structured Omaha System assessments. Flags care gaps before they escalate — not after the readmission.

Omaha System · structured · daily

Structured reports at Day 30 / 60 / 90

FHIR-compatible outcome package back to BCH. Days-since-discharge without ER return. Care hours logged. Omaha System scores — before/after Knowledge, Behavior & Status on each care goal, clinician-attested per visit. Patient-reported health status.

FHIR-compatible · QI-ready

Billable from day one — shared savings on top

The pilot's core work maps to Medicare codes that exist today, so reimbursement doesn't wait on shared-savings math: Transitional Care Management (CPT 99495/99496) for the 30-day post-discharge window, Remote Therapeutic Monitoring (CPT 98975–98981) for Sage's medication-adherence tracking, and Community Health Integration / Principal Illness Navigation (HCPCS G0019/G0022, G0023/G0024 — live since 2024) for the caregiver navigation. If the pilot then demonstrates measurable readmission reduction, co-op.care and BCH can structure a preferred referral arrangement on top — grounded in your data, not projections.

Billable now · referral later

These are BCH's patients. They're asking for this.

Boulder residents are signing on to ask BCH to build this partnership. This isn't a vendor pitch — it's a community health signal from the people you serve.

— Boulder residents have signed the community petition

See the full petition

Why the cooperative model

Turnover is the root cause. Ownership is the fix.

The home care industry's ~64% annual turnover isn't a staffing problem. It's a structural one — caregivers are paid poverty wages with no stake in the outcome. Cooperatives solve it by making caregivers owners.

Traditional agency model

$13–16 /hr take-home (1099 contractor, no benefits, no equity)

~64% annual caregiver turnover — PHI National Home Care Survey, 2023

0% ownership stake or board representation

Patient continuity: whoever's available that shift. The caregiver who knows Mr. Rivera's medication schedule may have left last Tuesday.

co-op.care

$25–28 /hr W-2 wage + benefits + equity stake in the cooperative

~30% annual turnover at worker-owned cooperatives — roughly half the industry rate (CHCA benchmark, the largest US homecare co-op)

1/3 of co-op board seats held by worker-members

Patient continuity: the same person who watched Mrs. Chen for 60 days notices the change in her gait before BCH hears about it — because she shows up every visit.

Metrics your quality team can actually use

Every data point defensible. Every outcome measured and structured. Formatted to plug into your quality reporting infrastructure.

Day 0 – 30

Readmission prevention window

Days-since-discharge without ER return. The metric CMS measures under HRRP. Early-warning flags pushed to your care team before a call to 911.

Weekly reports

Adherence + vital trends

Medication adherence rate. Mobility trajectory. Nutrition flags. Sleep disruption. Logged against the Omaha System's 42-problem taxonomy — the clinical standard for home care.

Day 30 / 60 / 90

FHIR outcome packages

Structured data export for your QI team: Omaha before/after Knowledge·Behavior·Status scores, care hours per patient, caregiver-continuity rate, patient-reported health outcomes.

The ROI case

What one prevented readmission is worth to BCH

The HRRP penalty is visible. The margin cost of avoidable readmissions is larger — and mostly invisible. Use the slider to estimate BCH's exposure with your actual discharge volume.

Monthly discharges — HRRP conditions 40

Current readmission rate vs. CMS expected +8%

HRRP conditions: CHF · COPD · pneumonia · TKA · THA · AMI · CABG.
CMS publishes your facility-level excess readmission ratios annually.

— Estimated excess readmissions per year

— Estimated annual cost — margin drag at $15,000/readmission

— If co-op.care prevents 20% of excess readmissions

— Net benefit — 10 memberships at $59/mo cost $7,080/year

Break-even math: At a baseline 18% readmission rate and 10 families enrolled, co-op.care needs to prevent fewer than 1 readmission per year to cover its full membership cost. The average prevented CHF readmission saves $21,000 in combined direct and indirect costs (AHRQ 2022). Structured transitional care is among the most evidence-backed ways to prevent these readmissions — randomized trials of the Care Transitions Intervention and the Transitional Care Model report 30-day reductions of roughly 20–40%. One patient. One visit. Paid for.

Sources: AHRQ Healthcare Cost and Utilization Project 2022 · CMS HRRP Final Rule 2024 · PHI National Home Care Survey 2023 · Coleman Care Transitions Intervention (Arch Intern Med 2006) · Naylor Transitional Care Model

Why this only grows: the HRRP penalty is the floor, not the ceiling. As health systems take on real insurance risk, every prevented admission stops being penalty-avoidance and becomes margin. That shift is already underway: provider-sponsored health plans rose from 18.3% of US hospitals in 2018 to 27.2% in 2023 — and 38.8% among nonprofit systems, the highest of any segment (JAMA, May 2026). The more risk BCH carries for its aging population, the more a cooperative care-delivery layer that keeps people home becomes infrastructure, not a line item. co-op.care is built to be that layer — and the worker-ownership model is the same anti-extraction, community-benefit logic a nonprofit system already runs on.

Source: Chen et al, "Growing Trends in the Payvider Model and US Hospital Systems Owning Health Plans," JAMA 2026;335(24):2162-2164.

10 families. 90 days. No contract required to start.

We don't need a formal partnership agreement to run a pilot. We need a designated care transition contact at BCH and a referral pathway. Everything else is co-op.care's problem to solve.

BCH provides: 10 discharge referrals from your care management team. Your selection criteria — you define the qualifying patient population (CHF, COPD, TKA/THA, pneumonia — your call). Your care managers can refer directly at co-op.care/recruit-bch — no portal login, no paperwork to start.

co-op.care provides: Named caregiver assigned within 24 hours. Physician oversight (our Chief Medical Officer). Daily Sage AI monitoring. Weekly status pings to your designated care transition contact.

At 30 / 60 / 90 days: Structured outcome report in FHIR — for your QI team to evaluate, compare against your readmission baseline, and present up the chain.

If it works: We structure a preferred referral arrangement based on demonstrated shared savings. If it doesn't, you have clean data explaining why — and so do we. No lock-in either way.

Start the conversation

Start a conversation

For BCH leadership, care management, and community health team members. We'll follow up directly — no auto-responders.