Care That Doesn’t End at Discharge
Follo Health was born from a simple, but critical observation:
Great care was happening inside the hospital — but breaking down the moment patients left.
The Origin Story
Dr. Nimish Patel has spent over 14 years caring for patients across hospitals and skilled nursing facilities—on the frontlines, where the stakes are highest. He seen the best of healthcare inside the hospital: life-saving interventions, dedicated teams, and patients stabilized against the odds. But he also seen what happens next. Patients discharged with instructions—but no real support. Medications misunderstood. Follow-ups missed. Conditions worsening quietly at home—until he return, often sicker than before. Not because the care was lacking— but because the system stopped too soon. He recognized a critical truth: the most vulnerable moment in a patient’s journey isn’t inside the hospital—it’s after they leave.
So he built Follo Health. A physician-led model designed to extend care beyond discharge—combining Transitional Care Management, Remote Patient Monitoring, and Chronic Care Management into one continuous, coordinated system.
Because patients don’t just need care at discharge— they need someone to stay with them after. And that’s exactly what we do.
- Follow-ups weren’t scheduled
- Medications weren’t managed properly
- Patients were confused or unsupported
- Communication between care settings broke down
- Avoidable 30-day readmissions.
- Frustrated care teams.
- Worse patient outcomes
Dr. Patel realized something fundamental:
The biggest gap in healthcare isn’t inside the hospital or skilled nursing facility — it’s what happens after. Hospitals are being held accountable for readmissions but don’t have a reliable system to control what happens once patients leave. That gap needs to be owned
Follo Health was built to become that missing layer.
A physician-led, execution-focused platform designed to ensure that every patient is:
- Contacted
- Guided
- Scheduled
- Monitored
- Supported
After they leave the hospital.
What Makes Follo Different Follo Health isn’t just a follow-up service. It is a post-discharge infrastructure system for modern healthcare organizations.
- Clinical expertise
- Operational discipline
- Technology-driven tracking
- Real accountability
To ensure that patients don’t fall through the cracks.
Mission
To eliminate preventable readmissions by owning the care journey after discharge.
Our Vision
A healthcare system where:
No patient feels lost after leaving the hospital • No provider lacks visibility into patient outcomes • No readmission happens due to preventable gaps in care
Why Hospitals & SNFs Partner With Us
We solve what they cannot control alone. We extend their care beyond their walls — with structure, speed, and accountability.
Under Medicare’s value-based care model, hospitals and skilled nursing facilities are increasingly held financially accountable for patient outcomes after discharge. Medicare programs such as the Hospital Readmissions Reduction Program (HRRP), Medicare Transitional Care Management (TCM), and bundled payment models directly tie reimbursement to post-discharge performance.
The reality is simple:
Medicare doesn’t stop at discharge — and neither do we.
We close the critical gap between discharge and recovery by ensuring patients receive consistent, structured follow-up aligned with Medicare care standards and reimbursement requirements.
Through our model, we support:
Rapid post-discharge engagement within Medicare TCM timeframes
Ongoing care coordination that meets Medicare documentation and compliance standards
Medication reconciliation and adherence aligned with Medicare guidelines
Continuous monitoring to prevent avoidable Medicare readmissions and penalties
For hospitals, this translates to:
Reduced Medicare readmission penalties (HRRP)
Improved Medicare quality scores and CMS star ratings
Stronger performance under Medicare value-based reimbursement programs
For SNFs, this means:
Better patient outcomes under Medicare-covered stays
Reduced rehospitalizations that impact Medicare reimbursement and margins
Stronger alignment with hospital partners focused on Medicare performance metrics
We don’t just support care — we align it with how Medicare reimburses, measures, and rewards outcomes.