The most expensive gap in care is the 30 days after discharge. We close it — and hand you the proof.
A neighbor and a conductor in the home for the weeks after a hospital stay, priced against the readmission you already pay to avoid. Not another dashboard to install — the operator who actually shows up, and the only care-transition partner that returns a verified outcome ledger instead of just an invoice.
Discharge is the moment the system hands the patient back to a family that was never trained for it — and walks away. The instructions don't get followed, the follow-up gets missed, the warning sign goes unnoticed, and three weeks later an ambulance undoes a $30,000 stay. Every tool built for this gap detects: the fall sensor, the remote-monitor, the risk score. None of them show up at the kitchen table. The missing piece was never more detection. It was a person who answers what now.
That is the one thing willingness-to-pay is built for. Families won't buy "aging support" before a crisis — but at discharge, the need is concrete, the clock is running, and the payer is already on the hook. The transition home is where the money is won or lost, and it is won by presence, not by another alert.
We place a vetted neighbor and a care conductor in the home for the 30 days after discharge: medication reconciliation in plain language, the follow-up actually booked and attended, the home made safe, the warning signs watched by someone who knows the person — and a physician attesting each clinical step. We price that presence against the readmission you already pay to avoid. One prevented readmission funds the whole cohort.
A 30-day transition costs a fraction of one readmission.
We don't bill you for activity. We're measured on the metric you already report:
fewer 30-day readmissions · more days kept at home.
Outcomes-linked from the first cohort. The proof is the product.
Everyone else in this market sits in one of three crowded corners: a company that sells a tool, a service that monitors from a distance, or a staffing app that fills the visit with gig labor that churns. We sit in the one corner that's empty — and it's three things at once.
In the home, not on a screen.
An agent can coordinate a plan; it cannot make the bathroom safe or sit with a frightened family at nine at night. The well-funded names you're already hearing from are virtual-first — we are the in-person last mile underneath them.
Owned, not gig.
The caregiver who shows up holds equity in the outcome. That is the retention and change-management layer a 1099 staffing vendor structurally cannot buy — and the reason our visits don't churn the way the companion-care platforms did.
Proven, not self-reported.
Because we run our own care, the outcome ledger comes from ground truth, not a slide. That's the difference between a partner you have to audit and a partner you can trust.
The stack detects. We're the human who answers what now — and the ledger that proves it worked.
Built for whoever already owns the risk — or the patient
Five doors into the same transition layer. Each one already carries the cost or the case — we make the readmission not happen and hand back the evidence.
SSBCI now rewards proven outcomes
Your Stars rating is worth millions in quality-bonus dollars, and the measures that move it — medication adherence, transitions of care, follow-up after hospitalization — all live in the 30 days we own. We close those HEDIS gaps in the home and hand back the quality-grade outcome ledger to prove it. (Best fit for plans that don't already own their own home-health arm.) Plus, we're the care coordinator a D-SNP is already required to staff.
Start a plan pilotReadmission penalties meet the CHNA budget
The transition you can't staff for, run by a cooperative that lives in the neighborhood — funded where the readmission penalty and the community-benefit obligation already point. We're the discharge partner, not another EHR module.
See the hospital caseYour MA contract needs the number you can't yet show
Only ~28% of AAAs can measure the financial value of their own services — which is why MA contracts stall. We deliver the care-transition outcome and the verified ledger that turns your trusted local network into a performance-based revenue line.
Partner with your AAACapitation already rewards days at home
Under full risk, every avoided hospitalization is margin and every honored decision is a better outcome. We're the decision-honoring last mile that keeps participants home — without the facility build.
See the PACE proposalWe're the in-home arm your telehealth model is missing
Virtual navigation can diagnose and coordinate; it can't make the home safe or sit with the family at 9pm. We deliver the in-person last mile and the verified-outcome ledger underneath your program — a partner, not a competitor.
Plug in your programYour workforce is the second patient
The employee whose parent just left the hospital misses work, burns out, and leaves — the hidden tax on every plan you self-fund. We carry the transition for their family, and the return lands in absenteeism, retention, and claims at once.
See the employer caseEvery transition produces a verified record, not a marketing anecdote: who delivered care (identity), that the visit happened (double-confirm or EVV), and that it helped — scored on the Omaha System and mapped to FHIR, with a physician's attestation anchored to evidence a payer or a regulator already trusts. That is the standardized, shareable outcome data this entire market is missing — the thing a hospital's risk model, a plan's quality bureau, and an AAA's funder all need and none can generate. We can, because we're in the home.
Pick the one number you'll be judged on — readmissions avoided or days kept at home — and we build the whole ledger to defend it. A UK peer (Cera) reports up to a 70% reduction in hospitalizations from exactly this model; that's the benchmark we measure ourselves against, in the open.
We don't sell care. We sell what care proves.
The same four-step loop that took the UK's Cera to a reported 70% fewer hospitalizations — instrumented in co-op.care from the first family, and visible live on our dashboard.
Every visit, logged
Omaha-scored observations — mobility, mood, medication, hydration — captured at the kitchen table. Ground truth, from family one.
See it on the dashboardSeven days ahead
Sage surfaces early-warning patterns before they become emergencies — the benchmark Cera hits at over 80% accuracy. Knowing who's at risk is now the cheap part: recent health-system models forecast ~900 diseases at AUC 0.87 on something small enough to run on a phone. The scarce thing is the accountable human who acts on the flag.
How the intelligence worksIn the home, before the 911 call
A neighbor or conductor adjusts the plan or escalates to the medical director — nipping it in the community, not the ER.
Meet the conductorWritten to the ledger
Every prevented event becomes a verified record — Omaha mapped to FHIR, physician-attested — the proof a payer trusts.
The attestation layerSmall and instrumented: one cohort of recently-discharged members in the Front Range, a defined readmission baseline, outcomes-linked pricing, and a shared dashboard from day one. No platform migration, no year-long procurement — a neighbor in a home next week, and a number you can take to your board in ninety days.
co-op.care is pre-scale and Boulder-first. The outcomes above describe the model and its benchmarks, not yet-achieved results — pilots are designed to produce the proof, in the open, with you.