Carl Maronich (Host): Welcome to Wellness Waves, where healthcare insights meet expert analysis. I'm Carl Maronich. And today, I'm joined by Carrie Hodge, CEO and Co-Founder of Dimer Health and Deborah Visconi, President and CEO of Bergen New Bridge Medical Center. And today, we're going to be talking about the vital role of mobile app support in easing the transition from hospital to home for patients. Welcome to both of you.

Deborah Visconi, MS: Thank you, Carl.

Carrie Hodge, MS: Thank you, Carl.

Host: And, Carrie, let's start with you. And I'll ask, what inspired you to co-found Dimer Health and how has your background really influenced the company's mission?

Carrie Hodge, MS: Thanks for the question, Carl. And thanks for having me. So, my background is I'm a physician assistant from New Jersey. I've worked all over the place over the state. And as a clinician and a clinical leader in the space, I always used to say that the ER is like the catcher's mitt for patients as they come in or come back. And there are so many times when people would come through the door, and my colleagues would say, "Well, if only if they had X, Y, or Z before they came back, they would've never had to come back to the hospital." We all know that early intervention on problems helps the problems from exacerbating and becoming more and more complicated. And so, this was always something that just was a presence.

And then, my own experience as a patient and my experience working for another startup, really thinking about how do we reduce readmissions and divert patients from having to come back to the ER contributed to this passion I had for this space and transitionIst medicine as we're calling it. And after some work that I had done, we realized that it really doesn't take a lot to make a big difference for people, but it's really getting care to people where they're at and being able to scale that with technology that I felt would make a big difference in that.

Host: Very good. And Deborah, how has Bergen New Bridge Medical Center evolved in its approach to transitional care since your leadership?

Deborah Visconi, MS: So, Bergen New Bridge Medical Center, the largest hospital in the state of New Jersey, we have 1,070 beds. And we are a safety net provider in Bergen County and serving the greater Northern New Jersey area. We serve the most vulnerable people in our communities. And so, being a safety net provider, we also really think and act like an innovator in our space. Always looking at ways that we can innovate around the human spirit and partnering with Dimer on this transitionist model really aligned with our mission to provide access to high quality care.

For us, innovation isn't about technology necessarily for its own sake, but it's about removing barriers, improving access, and delivering better outcomes for the communities that we serve and those who need us the most. And so, we've made a deliberate decision to lead in this area, not follow, when it comes to integrating meaningful technology into care delivery to make sure that we are there for our communities when and where they need us.

Host: What are some of the most common challenges that patients face when transitioning from the hospital to home?

Deborah Visconi, MS: Well, that we find is the largest gap in care. When people leave a hospital, whether you leave from an emergency department or you get discharged, that's where you see people fall through the cracks because they either don't have a primary care provider to follow them, or they don't have good care management.

And so for us, that's why this was such an important model to be able to link those people with a clinician right when they get discharged and identify what needs they have, make sure that they get their followup care. If they don't have a primary care provider, link them up with someone. If they need specialty care, we see a huge amount of people with diabetes or heart conditions or asthma that need followup care with specialists or primary care. They need imaging, radiology, laboratory.

And so, we make sure through using the Dimer platform that they get linked up right after they get discharged from the hospital, again, be it from the emergency room or from an inpatient unit, so that we can continue that continuity of care and assure that they get the care that they need.

Host: And how can the a mobile platform really play a critical role in mitigating the risk for patients once they've been discharged?

Carrie Hodge, MS: One, I think Deb has such an incredible perspective on the patients that our hospital's serving and the needs that they have. But the challenges aren't just at Bergen New Bridge, the concept of this time between the discharge and the followup. We look at it as its own medical specialty.

So, the hospitalist takes care of the patient in the hospital. The transitionist takes care of the patient as they are transitioning home. And this way, patients, in our traditional healthcare model, people receive their discharge and they go through the doors of the healthcare institution. And the care goes from the responsibility of that institution to the patient and their caregivers. And that's where things fall off. On average, it takes patients 30 days across the country to have a followup appointment after a discharge. And in that timeframe, so much could go wrong and the patient's health status is in flux. And then, you add on things like social barriers to care and access to care. All of those things make it harder and harder for people to be successful, especially when they're incredibly vulnerable and in a vulnerable health state.

So, the things that people need, they're not rocket science. We're not doing anything wild here. We're really just providing access to resources for patients as they're transitioning home so that that the great experience they have in the hospital can continue as they go home from like hour zero to the time they're handed back off to a primary care doctor or their specialist.

Host: Yeah. Well, Carrie, how specifically is the mobile platform designed to support post-discharge patients?

Carrie Hodge, MS: We know that the key to success for people is getting to them as quickly as possible and not letting that time between care lapse. So, we get to patients. On average, 85% of our patients are seen by a virtual provider within the first 48 hours after discharge. And then, from there, we virtually link arms with the person by staying connected to them through check-ins and proactive outreach. We also now have collected data on people so we know for different populations who's going to be the most successful when they have access to care and the proactive care outreaches. So, you know, we know for oncology patients that if we can connect with them and stay connected to them on days five and day seven after discharge, those are the most vulnerable times for those patients after they go home. So, we're able to stay connected to them through calls, texts, through the app, through multiple mechanisms.

Host: And Deborah, in what ways has Bergen New Bridge Medical Center collaborated with Dimer to enhance patient care?

Deborah Visconi, MS: So, that really goes to the crux of why we partnered with Dimer and really we're very disciplined and when and how we evaluate the technology that we put into use. And when we look at it, you know, does it improve patient outcomes? Yes, it absolutely improves patient outcomes because you capture those patients right When they're at their most vulnerable moment when they're leaving a hospital. Does it reduce burden on our workforce? I think it really helps our workforce, aligns with our workforce to be able to provide that care when those patients need it. So, I think it's not so much a reduction of workflow, but really just an enhancement of the current work that they do.

And then, does it advance health equity? Well, that's what we're all about, making sure that we provide access to extraordinary care for our communities and patients. And so, all those things that we look at when we evaluate a technology or a tool that we're using is what Dimer brings to us and our patients and our providers.

 But in addition to the technology piece, it blends it with human touch. Like, there's a person on the other end of that talking to our patients, reaching out and making that connection. And that's, again, what makes certainly our mission of being Bergen New Bridge, you know, treating with dignity and compassion and respect in equitable manner really aligns with what Dimer does with us.

Host: And Carrie, I'll kind of put that question to you as well. And from your perspective, how has it been working with Bergen New Bridge Medical Center in adopting this platform?

Carrie Hodge, MS: Well, I just have to say that I've been blown away honestly by the staff that I've worked with, that has been a part of this, from the leadership to the nursing on the floors of the hospital. Everyone is just so mission-driven and so dedicated to the patient population. And I am that way also. That's why we built Dimer Health to be accessible for everyone. And it's been really just refreshing to see that. And the motivation behind the work that people do.

So, I definitely want to give a shout out to Deb for the teams that she's built and the teams that are there. When there's multiple barriers for people, giving them great care, you know, you can give them great care in the hospital, but trying to set them up for success outside of the hospital is really challenging and everyone is so dedicated to that and is really beautiful. And I'm so happy that the technology that we are building can complement that spirit of the people that are a part of Bergen New Bridge including the patients and meet people where they're at and when they need it.

And one of the things that I think is like the most interesting about the technology and the evolution of technology and healthcare right now is that it allows that Bergen New Bridge spirit to reach to the people all the time, whenever they need it, so that whenever a patient reaches out their hand for help, that spirit of Bergen New Bridge is there to grab it. And we can really now think about process change and like the way that healthcare has always delivered care for the last few decades. We don't have to keep doing things the same way because AI now allows us to take a look at processes and take the best of the people and allow them to use that time to connect with patients and let the technology and the background extend that reach. So, almost like an amplifier. So, that's how I think of it.

Host: I was just going to ask, you know, one of the key words in healthcare seems to be access. Making sure that patients can access the care they need when they need it. Certainly, this technology And this platform has to be a big boost in that regard.

Deborah Visconi, MS: Oh, absolutely. And we're seeing already stronger adherence to followup care. People respond, they feel heard, they feel seen, they feel supported, not alone. Because when the Dimer, when the transitionist contacts them, they really talk about some of the things that are most scary when you leave a hospital. Medications, instructions, next steps. And then, it allows us to identify risks early through these intelligent alerts. So, we'll see it, it creates this continuous thread of care. It's not just a handoff and hope. It's a continuous thread that the patients feel connected back to that care.

Carrie Hodge, MS: Just, to add on to that, our team here sometimes makes fun of me because I'm like, "We give access whenever, wherever, and however," and it's a Shakira song. So, they're like, "What are you? Shakira care?" But yes, I really think that is the idea of how can we leverage the technologies that are out there, that are smart, that are enablers to meet people in a way that's meaningful to them.

And I think that's one of like the biggest breakthroughs in AI is that people can have access to care, meaningful access to technology in a way that has never met people where they're at before at the individual level. We've always addressed populations and now we can meet you, we can meet Carl, we can meet Deb, we can meet Carrie in a way that's meaningful to us.

So, I think that's what's so beautiful. And, you know, one of some of the things that we're finding from the work that we're doing is over 60% of the interactions that we have with our technology is after hours. So, it's when the traditional access to care shuts down, people go home at the end of the day. We get chats with our AI that knows you at like 2:00 AM and you know, "I'm scared, I don't know what to do." And traditionally, there's no other option than to go back to the emergency room. And that's hard if you're a single mom with three little kids that can't stay home alone and you need help. There's all sorts of access barriers that people have. But now, we can meet that person where they're at in a way that's best for them, and that's going to get them the best outcome.

Deborah Visconi, MS: This allows us to build that trust with our patients. And, you know, a huge part of healthcare is trust, trusting your providers. And so, implementing something like Dimer, it really builds that trust with patients because at 2:00 AM you know, when you're most scared and most vulnerable, there's someone helping you navigate and get you to the right place at the right time.

Host: Deborah, let me ask you, how has this played into your patient satisfaction scores and the things you're seeing in that regard?

Deborah Visconi, MS: Oh, tremendous. I mean, you know, our patients feel seen and supported and not alone after they leave us. And so, it also helps our providers because they have more transparency into that particular patient. It reduces anxiety at a moment when patients are most overwhelmed. And as Carrie mentioned, you know, a single mom at home at 2:00 AM.

And then, from a lot of our patients, it's assistance navigating those complex health systems. So, you know, for us, from a patient experience point of view, it really embodies one of the things that we hold so dear, which is we treat the illness but we care for the person.

Host: Carrie, let me ask you about advancements in technology. I mean, you know, we've gotten to a point where there have been so many of them. But what additional advancements are you seeing that will be coming down the road?

Carrie Hodge, MS: We know now 40% of conversations that happen on ChatGPT are related to people's health. And those also happen after hours. And I think the whole landscape of what does it mean to access care and who's delivering the care? Like, that's a very dynamic thing right now. And I think people are going to do what works the best for them and what's easiest for them. I believe that people staying connected to their care teams is the best thing for them. But if it's not convenient, they're not going to do it. And, you know, there's a lot of reasons why I've experienced those reasons why I was late to make a doctor's appointment or followup on something and because there just were too many other things that made it hard.

And technology is going to be able to break down those barriers. And I think health systems that are like really innovative and forward thinking like Deb with Bergen New Bridge are going to partner with the right companies and technology companies to make that access easier just as easy as going onto the internet and typing something in.

So, I really think that's where healthcare's going and how it's going to dynamically change. And it's a really interesting time, I think, for our health systems and payers because they want to stay connected to their patients, because it's the best thing for the patients to stay connected to their care teams.

And just even on the patient satisfaction question you asked, people love this experience of having access to care at their fingertips all the time. And that is reflected in our scores, that for our patients and especially the Bergen View Bridge patients, and people comment like, "I've never felt seen like this before or cared about like this before. I didn't know healthcare could be like this." We get really beautifully written comments back from patients. And we also connect it back and we ask them, "How does this reflect back on your experience with the health system or the referring doctor?" And it's always a positive correlation. So, really being able to extend the great work that they're doing in the hospital into the home allows Bergen New Bridge to stay connected in a really meaningful way. The patients love it.

Host: Very good. Deborah, let me ask you kind of to expand a little bit on some that we've already said, but this platform, how is it being adopted as the care team's kind of plan care strategy going forward?

Deborah Visconi, MS: So, you know, wrapped around our basic mission of providing that access to care. For us as a safety net, we're focused on equitable access to care and technology like this just adds to what we do and helps us through it. It helps us reach patients who might otherwise fall through the cracks. It helps us address those social determinants of health in real-time.

And innovation is meaningful if it closes gaps. And that's exactly what we're doing here with Dimer. And for us, we're building a culture here where clinicians are engaged in shaping the solutions for our patients. And we invest in technologies that make a measurable difference, improve those outcomes, and really truly creating a modern care model within a public health system because we're a public hospital, and again, serving the vulnerable communities.

Host: How might these kind of platforms help patients to try to live healthier lifestyles going forward?

Carrie Hodge, MS: There's a lot that's happening at the public level to help make access to care and technologies to improve just exactly that. So, it's not necessarily just about "You were discharged for your blood pressure. Now, we're only going to focus on your blood pressure." But also, how do we incorporate good lifestyle reminders, medication adherence, all of those things that all can be done through this interactive platform. So, I think it is actually really beautiful.

And also, engaging people's caregivers. So, the technology allows it that if you have a senior parent that, you know, you're worried about in New Jersey, but you live in Florida. Now through the technology, you can all stay connected and be on the same page about care and what is needed. So, I think the technology just breaks down a lot of those barriers to more holistic care.

Deborah Visconi, MS: Yeah. And I think it just sets us up as a healthcare system to be more connected, to be more proactive. And then, to be more personalized; to really understand that individual, not just their diabetes or their heart problems. It's really understanding the individual and being able to tailor our care paths to deliver that way.

Host: Are there any success stories specifically that you can share with us that this platform has created?

Carrie Hodge, MS: There's like so many. For us, I think just looking at the trends of when and how people engage. We recently did a report looking at all of the connectivity that we've done. So, the likelihood a person will have the ability to followup and that continuity of care, like Deb mentioned, is much higher through this. We have very specific feedback from patients about meeting them where they're at and in their language in a way they can understand. Debs and Bergen Newberg serve a very vulnerable population that have a lot of complicated needs that are their health state, but also other things. And so, being able to deliver things in a comprehensive way to people has, I think, really helped drive those outcomes.

Deborah Visconi, MS: Yeah, I don't have one specific example, but I think we can talk about just people with behavioral health and substance use disorder conditions. And those individuals need a lot of care and they need a lot of coordination and, you know, utilizing Dimer to identify those individuals has been really important for us and really has highlighted what some of the gaps that could occur when somebody leaves the hospital and still has some other comorbidities like behavioral health or substance use disorders. So, that's been a real added advantage to the program.

Host: Yeah. And Deborah, let me ask you to expand a little bit and talk about the diverse and underserved communities that you serve and how this has impacted your ability to care for them.

Deborah Visconi, MS: Yeah, I mean, it's phenomenal because, again, many times these individuals go back into their community and don't followup with the care that they need. And that's when your morbidity and mortality rises because people aren't getting the care or the screenings or the followup that they need. And so, being able to identify those individuals and reach out to them and provide them that access, resources for medication management or medication programs that can help them get the medications that they need, identifying the social determinants of health, whether it be food or housing insecurity. So, you know, we're able to identify those individuals and connect with them and assure that they get the resources and the connections that they need.

Host: As we wind down here, I'll ask both of you maybe to get out your crystal ball that all healthcare folks have, and tell us what you see happening in the virtual world with regard to transitional care technology that may be in the near future.

Carrie Hodge, MS: Yeah. So, we've been doing transitions of care and discharge from the hospital the same way for decades. People receive a stack of papers that are generic to their disease state. Eighty percent of people actually throw it away on their way home, believe it or not.

Deborah Visconi, MS: It's true.

Carrie Hodge, MS: And people don't do well. This is the most vulnerable time for people going home. And as length of stay in hospitals get shorter and ability to followup with the primary care and specialty care afterwards gets harder and harder, that gap is growing. And so, I really think that looking at transitions of care, it's a team sport. There's a lot of great work that's being done in case management, nursing, visiting nursing, social work. That's not necessarily what we do. We support that. But we're really now providing the provider-level decision-making and using the data for this predictive proactive care to help people get what they need and then align those resources.

Deborah Visconi, MS: Yeah. And I would just add that this transitionist model really allows patients to have that digital connection so nothing goes on tracked. And Carrie mentioned, you know, the whole metrics and how we track things. I mean, nothing goes on track. We will see everything. We have full transparency into a patient's care path and their needs. And so, I think that that's going to be the future. I mean, a really truly connected health system outside the walls of the hospital where it matters the most, actually.

Host: Well, Carrie Hodge, Deborah Visconi, you guys have given us some great insights into the successes you're having with this transitional care. We certainly thank you for your time. And congratulations.

Carrie Hodge, MS: Thank you.

Deborah Visconi, MS: Thank you so much.

Host: For more information, head over to newbridgehealth.org. If you enjoyed this podcast, please share it on your social channels and explore the full library of Wellness Waves for more topics of interest. I'm Carl Maronich. And this is Wellness Waves. Thanks for listening.