How It Works
How Post-Discharge Care Works at Dimer Health
Stay connected to personalized, physician-led care throughout your recovery, with ongoing guidance and 24/7 access to clinical support when you need it.
Who We Serve
Supporting Patients, Caregivers, and the Teams Behind Their Recovery
Whether recovering after a hospital stay, surgery, specialist visit, or supporting a loved one through recovery, Dimer Health provides continuous clinical support throughout the post-discharge journey.
For Patients
Leaving the hospital is only the beginning of recovery.
Dimer becomes your dedicated post-discharge medical team, helping you understand your care plan, monitor recovery, and get answers whenever you need them.
For Caregivers
Supporting a family member through recovery
Supporting someone after a hospital stay can feel overwhelming. Dimer keeps you informed with clear guidance, shared recovery plans, and access to confidence-boosting clinical support.
For Providers
Extending your care team beyond the visit
Dimer Health provides continuous clinical support between visits, helping patients stay on track while maintaining care continuity.
The Process
Eight Steps. One Clinical Team. One Seamless Recovery Journey
See how Dimer Health guides your recovery from discharge through your return to everyday life.
1
Connecting with Dimer Health at or After Discharge
Your recovery begins before uncertainty set in. Whether you’re introduced to Dimer Health before leaving the hospital or shortly after arriving home, our team connects you early to answer questions, explain what comes next, and ensure support begins during the critical first 72 hours.
Building Your Post-Discharge Care Profile
Before your first appointment, we review your discharge summary, medications, symptoms, follow-up needs, and recovery concerns. This gives your care providers a complete understanding of your health so every decision is catered to your individual recovery.
Your First Post-Discharge Clinical Appointment
Meet with a licensed Dimer Health clinician to review your recovery, answer questions, and create a clear plan for what comes next.
Your Personalized Post-Discharge Recovery Plan
Receive a personalized recovery plan that helps keep you, and your approved caregivers, informed every step of the way.
Continuous Monitoring and Clinical Check-Ins During Recovery
Regular check-ins will help monitor your recovery, answer questions, and identify concerns during the recovery stage of the process, before they become setbacks.
Coordinating Follow-Up Care, Specialists, and Ongoing Treatment
We help coordinate follow-up appointments, referrals, and ongoing treatment so that your recovery stays on track.
Around-the-Clock Access to AiME and the Dimer Care Team
AiME provides personalized guidance anytime, with your licensed clinical team ready to step in any time additional care or treatment is required.
Transitioning Care Back to Your Primary Provider
Once you’re ready, Dimer Health coordinates a smooth hand-off back to your primary care physician or specialist, ensuring you have continual support throughout the recovery process.
Get Started with Post-Discharge Care
Start your recovery with Dimer Health’s continuous clinical support, from discharge to home and through recovery.
The App + AiME
The App That Brings Your Recovery Together
The app brings your recovery together connecting your care plan, clinical team, AiME, and ongoing monitoring in one place.
Your personalized recovery plan is always up to date.
AiME provides guidance based on your medical information.
Clinical monitoring and outreach, all in one place.
Stay connected with your caregivers and clinicians throughout recovery.
Insurance Coverage
How Insurance Coverage Works for Post-Discharge and Transitional Care Management
Like other medical practices, Dimer Health bills eligible care through existing Medicare, Medicaid, or commercial insurance using Transitional Care Management (TCM) billing codes. There are no membership or subscription fees as eligible services are covered through your existing health plan.
Self-pay options available.
Get Started
Post-Discharge Care That Begins Before the Questions Start
Whether you’re returning home after a hospital stay, or looking to improve post-discharge care, Dimer Health provides physician-led support that starts early and stays connected throughout recovery.
Choose the path that’s right for you.
✓ No referral required ✓ Most major insurance accepted ✓ Physician-led care ✓ Available in licensed states
For Patients
Start Post-Discharge Care with Dimer Health
Connect with our clinical team within 24 hours of discharge, and begin your recovery with continuous physician-led support.
For Partners
Partner with Dimer Health to Reduce Readmissions
Extend clinical care beyond discharge and improve continuity of care with Transitional Care Medicine.
FAQs
Find quick answers to common questions about Transitional Care Medicine, post-discharge care, and recovery with Dimer Health.
Post-discharge care provides ongoing clinical support after leaving the hospital, helping patients recover safely while reducing the risk of complications and readmission.
Dimer Health delivers physician-led Transitional Care Medicine while billing as a medical practice using TCM billing codes through your existing healthcare plan.
Dimer Health provides continuous physician-led care throughout the recovery, as opposed to one-off virtual appointments for individual medical concerns.
Many patients are referred by hospitals or providers, but eligibility is dependent upon your care needs and location.
Dimer Health supports recovery after surgery, hospitalization, serious illness, and many other medical events requiring ongoing clinical care.