Dimer Health and Bergen New Bridge Medical Center Show How Dedicated Clinical Teams Can Improve Recovery After Discharge for Vulnerable Patients

Program identifies unmet care needs in 1 in 4 patients, connecting them to critical services and ongoing clinical support

FLORHAM PARK, N.J., Nov. 10, 2026 — For many patients, leaving the hospital is just the beginning of recovery. New symptoms arise, medications raise questions, and follow-up appointments can be difficult to arrange. For patients already facing barriers to healthcare, those challenges can quickly become more serious.

Bergen New Bridge Medical Center and Dimer Health are improving what happens after leaving the hospital.

Through their partnership, patients are connected to a dedicated clinical team that stays involved throughout the 30 days after discharge. Dimer Health's clinicians, known as Transitionists™, help patients manage their recovery, address medical concerns, and connect with the providers and services they need. AI-powered technology supports the team by answering routine questions, providing personalized guidance, and flagging concerns that need a human clinician's attention.

Bergen New Bridge Medical Center, a nonprofit safety net hospital in Paramus, New Jersey, provides compassionate, high-quality care to a diverse, multilingual community. Its mission is grounded in ensuring everyone can receive the care they need, regardless of their background, insurance coverage, or financial circumstances.

Recognizing that a successful recovery continues beyond the hospital stay, Medical Center leaders identified an opportunity to strengthen support for patients returning home. By helping patients obtain prescriptions, keep follow-up appointments, and connect with ongoing care, Bergen New Bridge sought to make the transition home easier, support recovery, and reduce the risk of preventable complications and readmissions.

Between January and October 2026, Dimer Health provided post-discharge care to 680 Bergen New Bridge Medical Center patients. Nearly one in four patients had unmet care needs requiring additional intervention, including access to primary and specialty care, behavioral health services, and insurance coverage.

Of the 154 patients with identified care gaps, 89% were successfully referred or scheduled for continued care, including 94 patients with confirmed appointments or established care.

The results revealed how much patients can need after leaving the hospital:

• Focused resources where they mattered. Dimer Health identified that 77% of patients did not require additional care coordination and were monitored by and treated by Dimer during their recovery window. The remaining 23%, or 154 patients, had needs requiring further attention and support to close care gaps.
• Uncovered needs that went well beyond an appointment. Of those 154 patients, 60% needed a specialist referral, and 25% needed help with primary care, including finding a new doctor or accessing charity care. Another 38% needed services such as imaging, lab work, Medicaid enrollment, substance use treatment, or home health support. One in five (20%) needed help in two or more of these areas at once.
• Connected patients to ongoing care. Nearly nine in ten (89%) patients with identified care gaps were successfully referred or scheduled for continued care, including 61% with confirmed appointments or established care. Only 10% could not be reached, reflecting the challenges facing safety-net patients, including unstable housing, language barriers, and difficulty maintaining contact after discharge.
• Earned high marks from patients. Patients rated the program 4.9 out of 5 for satisfaction and gave it a Net Promoter Score of 91.

"Patients don't stop needing care when they leave the hospital, but too often, that's when they lose access to it," said Caroline Hodge, PA-C, MBA, CEO and co-founder of Dimer Health. "Our Transitionists™ take responsibility for those next 30 days. They're there to answer questions, recognize when something isn't right, and step in before a small concern becomes a bigger problem. Bergen New Bridge is showing what continued care can mean for patients who need it most."

Based on the results, Bergen New Bridge is expanding the program to other hospital units.

"We want our patients to feel supported and confident about their recovery when they go home," said Deborah Visconi, President and CEO of Bergen New Bridge Medical Center. "That means understanding their lives, from work and family responsibilities to language needs and a safe place to recover. With Dimer Health, we can stay connected, answer questions and help our patients get the care and support they need to keep getting better."

Dimer Health's approach combines AI-powered technology with 24/7 access to licensed clinicians who specialize in post-discharge care. AI helps patients get answers to routine questions and alerts the clinical team when concerns arise. Transitionists™ then assess, treat, coordinate, or escalate care as needed, maintaining clinical responsibility during recovery before transitioning patients back to their primary care providers and specialists.

For hospitals like Bergen New Bridge, this provides a way to extend clinical care beyond discharge without adding hospital staff or building new infrastructure.

More than 35,000 patients have been referred to Dimer Health for care in the 30 days after hospital discharge. Across its programs, Dimer Health has reduced 30-day readmissions by 42%. For patients who did need to return to the hospital, it shortened their stays by 33%, an average of two fewer nights in the hospital.

Media Contact:
Supreme Communications on behalf of Dimer Health
[email protected]

SOURCE Dimer Health