One care journey. Three torn systems.
Cohezon. A Care Continuum platform built to connect what no single EHR can: hospitals, post-acute providers, primary care, and the patients moving between them.
That tear has a cost. And fixing it has a deadline.
Effective 1/1/26, CMS TEAM (Final Rule CMS-1808-F) raises the stakes for hospitals in selected regions that don't coordinate care.
Care Transition
23.3%
Return to the hospital, or worse1
A 2014 JAMA study of Medicare patients found nearly one in four discharged to a skilled nursing facility were readmitted or died within 30 days.
Care Coordination
$4,500
Higher cost per fragmented patient2
Chronically ill patients whose care is scattered across providers cost thousands more and hit more quality gaps.
2 - Frandsen et al., American Journal of Managed Care, 2015.
Patient Navigation
60%
Understand their post-discharge plan3
Only three in five patients grasp what happens after they leave. The rest are guessing. And that doesn't bode well for anyone.
Today's tools each only fix one slice.
Every tool here owns one piece of the handoff. EHRs document inside a single organization. Referral platforms shuttle packets between inboxes. Navigation apps hand patients information with no clinical context.
The patient moves through all of them.
Separate tools can’t share a patient.
Every care transition crosses organizations. When each one runs its own tool, every handoff becomes a copy (a fax, a retyped referral, a printed list) that’s out of date the moment it’s made. Separate tools can be connected. They can’t be made to agree.
Cohezon is built around the patient instead. The family, the case manager and the next provider work from the same information, so a change made once reaches everyone. Hospitals free beds sooner, providers get patients they’re ready for, plans keep members in network, and families make a choice they understand.
Put the patient at the center, and everyone comes out ahead.
Cohezon:
Mena
Member Navigation Assistant
Clear, plain-language choices for families, before, during, and after a hospital stay. Always free.
Cohezon:
Dina
Discharge Navigation Assistant
One shared workspace for case managers and post-acute providers. No hospital IT interface to start.
Cohezon:
Post-Acute
Marketing & Analytics Support
An accurate, complete profile that families and case managers can trust. Free to claim.
Cohezon:
Payor
Member Navigation for Plans
Reach members’ families, in their own language, at the moment they choose post-acute care.
Built with the people who do the work.
RN case managers and post-acute design partners have shaped Cohezon from the first sketch.
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DiMe
"It is rare to find partners who are as clear-eyed about the realities of healthcare, and who are thinking creatively about what it will actually take to meet patient and clinician needs."
— Digital Medicine Society (DiMe)
Design Partners
10 post-acute organizations signed as design partners across skilled nursing, home health, home care, hospice, and senior placement agencies.
From the field
"Dina:Clear is an innovative tool that helps patients discover nearby facilities like ours that they might otherwise miss and reduces avoidable bed days by revealing these 'hidden gems.'"
- Ian Cook, Business Development, Moraga / Rossmoor / Tice Valley Post Acute
"Dina:Clear makes it easier for hospitals to connect patients with the right hospice care, faster. It's helping us build relationships and serve families when timing and compassion matter most."
- Jose Fernandez, Sonata Hospice