Adaptive Care Transition — Strategy Sprint

The thirty-day blindness.

In the hospital Full clinical visibility

→

At home The caregiver, invisible

→

Day 30 A preventable readmission

You have clinical visibility before discharge. You lose it the moment they go home — for the thirty days when readmission risk is highest.

The cost of blindness

What post-acute readmissions really cost.

20–25%of Medicare discharges readmit within 30 days

30–40%of those are caregiver-driven — stress, confusion, escalation delay

Not non-compliance. Not bad luck.

What stays invisible

Stress patterns that precede escalation by days

Medication slips from overload, not refusal

Decisions made alone, at three in the morning

Staff anxiety about what happens after discharge

You cannot intervene on what you cannot see.

The caregiver paradox

We have been optimizing the wrong question.

What we measure

Did the patient understand? Was the referral submitted? Were the boxes checked?

Task completion.

What predicts readmission

Is the caregiver overloading? Are they recovering between demands? Can they still learn and decide?

Nervous-system state.

What if you could see it?

Early warning for the invisible crisis.

The thirty days after discharge

Intervention window

Discharge Day 5–7 · rising strain Patient stays home

You would intervene before the panic — and prevent the readmission.

Our approach

Behavioral systems mapping.

Workflow Intelligence

Map the discharge journey as it is actually lived — where coordination breaks, and where the caregiver absorbs invisible burden.

Caregiver Burden Mapping

Locate the stress-point moments, and read caregiver state through behavioral and physiological markers, including HRV.

Adaptive Intervention Design

Design low-friction support timed to the pre-escalation window — a deliverable response your team can carry, not another app.

What we deliver

A ten-week sprint, in four phases.

Weeks 1–2

Discovery

Map the workflow, set baseline metrics, define the caregiver cohort.

Weeks 2–6

Proof

A caregiver cohort uses a simple app through the critical window. We test whether escalation is predictable.

Weeks 5–8

Design

Turn what caregivers showed us into workflow changes, staff training, and measurement.

Weeks 8–14

Results

Run the pilot, measure outcomes, deliver the analysis, case study, and roadmap.

You don't just get recommendations. You get evidence, a blueprint, and a case study.

The proof layer

We don't ask you to bet on a framework. We prove it.

A small cohort of your caregivers uses a simple app through the thirty-day window. Stress state, friction, and HRV are read via Somatag or compatible wearables. When pre-escalation signals appear, we trigger a quiet micro-intervention.

Proof it predicts

that caregiver stress patterns precede escalation.

Evidence it works

before you commit to scaling it.

A case study

from your own population, to fund what comes next.

What success could look like

Illustrative scenario — modeled figures, not a completed engagement

A heart-failure cohort at 25% readmission.

~18%lower 30-day readmission (25% → ~20.5%)

~40%fewer post-discharge escalation events

~30%improvement in caregiver burden scores

5–7dadvance warning before a readmission event

These figures model the kind of change the approach is designed to produce. A live engagement is how they would be tested.

Who this is for

The right partner for this work.

This engagement fits systems that

Carry high readmission in a specific post-acute cohort See caregiver capacity as clinical, not only logistical Want to move from reactive management to prevention Are ready to pilot with clear outcomes and a scaling plan

Why Kutuhala

HRV and behavioral research, grounded in a multi-year caregiver study Interventions that integrate into your workflow, not add to it Replicable blueprints — caregivers as clinical assets, not variables

The engagement

Structure, scope, and timeline.

What's included

The full Kutuhala team — research, strategy, design, analysis All deliverables across the four phases Weekly check-ins and monthly steering committee A publication-ready case study

Timeline 10 weeks

active, with two to four weeks after for case-study finalization.

Investment is sized to your cohort and shared in a first conversation.

What happens next

A phased path to scale.

This engagement

Prove it

Strategy sprint, pilot, and an evidence-based blueprint.

Months 3–6

Implement

Roll out across the primary cohort; measure at scale; refine.

Months 6+

Build infrastructure

Somatag or a caregiver app as an institutional tool; expand cohorts.

In parallel

Position

Publish the findings; present; lead on caregiver-centered care.

One system. One cohort. One proof point. Then you scale it.

Why now

The emerging frontier of post-acute care.

The urgency

Readmission penalties are real and growing Caregiver burnout is at crisis levels Payers are demanding innovation in post-acute care

The opportunity

Early movers set the standard for caregiver-centered design The work is publishable — clinical and operational credibility The approach scales across cohorts — cardiac, stroke, orthopedic

Most systems are optimizing process. Few are treating the caregiver as a clinical asset.

The invitation

The patient is discharged. The care is not.

What if you could see the break coming — and intervene before the crisis? This engagement is designed to answer that with evidence. Your data. Your caregivers. Your outcomes.

The next step

A ninety-minute working session with your clinical team.

Christine Galligan Kutuhala Studio hello@christinegalligan.com · christinegalligan.com