For hospitals and health plans
Help families get through the first 30 days at home
KISOP gives each family a Family Care Book, a trained helper for the first month, and an easy way to share the work with relatives and neighbors. We are working to make it free for families. You sponsor it for the patients you send home.
What happens after discharge shows up in your numbers
Readmissions
Many early readmissions trace back to the first days at home: a warning sign nobody recognized, a medicine taken twice, a follow-up visit that never happened.
Follow-up and medicines
Health plans are measured on follow-up after discharge and on reconciling medicines. The helper books the visit with the family and helps them get the medicine list reviewed by a pharmacist or nurse in the first days.
Family caregivers
63 million Americans are family caregivers. More than half manage medical tasks such as medicines and wound care, and only about one in five has had training.
AARP and the National Alliance for Caregiving, Caregiving in the US, 2025
A pilot you can start quickly
We are looking for hospital partners. The first partner helps shape the program with us.
Families in the pilot get the book and a helper from before discharge through day 30. You get a weekly report on the measures you choose, and an independent evaluation at the end.
- Families
- 50 to 100
- Setting
- One hospital, or one unit or service line
- Length
- Six months of enrollment, 30 days of support for each family
- Starting condition
- Heart failure, or one you choose
- Languages
- English and Spanish
- What we measure
- Follow-up visit within 7 days. Readmissions and emergency visits within 30 days. Medicine list reviewed with a pharmacist or nurse. Caregiver strain, with a short standard survey. Family experience.
- Evaluation
- An independent evaluator, agreed with you before we start
- Cost
- Sized with you, so that one department can approve it
Built on care transitions research
Our approach draws on published research on care transitions. In a randomized trial of the Care Transitions Intervention, patients who had a transitions coach, a home visit and a personal health record were readmitted less often in the first 30 days: 8.3 percent, compared with 11.9 percent in the control group.
Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Archives of Internal Medicine, 2006.
KISOP adds the family and neighbors, Spanish from the start, and records the family keeps.
What we need from you
- A clinical champion, such as a heart failure nurse or a case management lead
- A way for your discharge team to refer families
- Help measuring follow-up visits and readmissions from your own data
- A sponsor for the pilot budget
What we will never do
- Sell or share information about patients or families
- Ask for exclusive rights. What one sponsor pays to build, every community can use.
- Lock you in. If the partnership ends, families keep their books and copies, and the tools stay free.
- Put ads in front of families
Paying for it over time
Hospitals often fund programs like this from community benefit or care transitions budgets. Health plans can fund it as part of their support after discharge.
Other ways to take part
Dementia care programs
If you are part of Medicare's GUIDE dementia care model, the book and the helper fit the caregiver support you already give.
Foundations and companies
Sponsor books and helpers for one community, or for the families of your own employees.
Community groups
Churches, senior centers and community health workers already help families. We work to support your efforts.
Start with a 30-minute conversation
We will walk through the pilot with your team.
Set up time with our team