Program overview

For vascular patients, the greatest risk often begins after discharge, when dressing changes are missed, medications are not adjusted, and early warning signs go unnoticed until they lead to costly readmissions. Own Health’s Transition-of-Care Program turns that vulnerable window into a tightly monitored episode of care that extends hospital-quality standards into the home. Each discharge is supported by a digital care bundle that runs for 30 to 90 days, depending on wound severity and comorbidities.

System challenge addressed

Discharge pathways for vascular patients are frequently fragmented. Many patients are discharged without timely access to home care, proper dressings, or scheduled follow-ups. These gaps lead to preventable complications, ED visits, and readmissions that could be avoided with earlier detection and coordinated escalation.

Model of delivery

Within 24 hours of discharge, patients receive a standardized kit with advanced dressings, offloading equipment, and a personalized schedule of community nurse visits generated through our clinical decision support system (CDSS), Doctor Dash. The platform also books virtual nurse practitioner follow-ups at key intervals, during which wound images, best-practice guidelines, Doppler readings, and medication reconciliations are reviewed by Own Health’s clinical command centre. If deterioration is detected, vascular surgeons can escalate care immediately, often securing same-day imaging or OR access.

The program also includes patient and caregiver coaching at bedside, just-in-time supply logistics coordinated through national distributors, and automated alerts based on Doctor Dash’s wound-healing analytics. When healing stalls, the system prompts local nurses to escalate or adjust care.

Impact and value

Hospitals and home and long-term care organizations that implement the Transition-of-Care Program reduce median length of stay by 50% and achieve a 25% reduction in 30-day readmissions. The program supports alternate level of care and QBP performance targets while improving safety, continuity, and patient satisfaction.

How to get started

Invite Own Health to conduct a transition-of-care discovery session. We will analyze your discharge patterns, identify gaps in post-acute continuity, and co-design a rollout plan aligned with your service provider partners and funding model.