Self-Managed Chronic Care
Self-Managed Chronic Care
Self-Managed Chronic Care
Self-Managed Chronic Care
Award Nominations'26
Award Nominations'26
Award Nominations'26
Award Nominations'26
Award Nominations'26
30-day hospital readmissions cost the US healthcare system $52.4 billion annually. Despite over a decade of Medicare penalty programmes, 78.6% of hospitals still faced readmission penalties in FY2025, totalling $320M in a single year. The gap isn't clinical complexity. It's the unstructured, unsupported first 30 days at home.
30-day hospital readmissions cost the US healthcare system $52.4 billion annually. Despite over a decade of Medicare penalty programmes, 78.6% of hospitals still faced readmission penalties in FY2025, totalling $320M in a single year. The gap isn't clinical complexity. It's the unstructured, unsupported first 30 days at home.
30-day hospital readmissions cost the US healthcare system $52.4 billion annually. Despite over a decade of Medicare penalty programmes, 78.6% of hospitals still faced readmission penalties in FY2025, totalling $320M in a single year. The gap isn't clinical complexity. It's the unstructured, unsupported first 30 days at home.
Fall 2025 | Prof. Silke Bochat
Fall 2025 | Prof. Silke Bochat
Fall 2025 | Prof. Silke Bochat
Fall 2025 | Prof. Silke Bochat
Service Designer
Service Designer
Service Designer
Service Designer
MA Final Project
MA Final Project
MA Final Project
MA Final Project
Timeline: 6 Months
Timeline: 6 Months
Timeline: 6 Months
Timeline: 6 Months
Challenge
Challenge
Challenge
Challenge
Without a caregiver at home, patients absorb all the coordination work that hospitals assume someone else will do, and most aren't equipped for it.
Without a caregiver at home, patients absorb all the coordination work that hospitals assume someone else will do, and most aren't equipped for it.
Without a caregiver at home, patients absorb all the coordination work that hospitals assume someone else will do, and most aren't equipped for it.
Approach
Approach
Approach
Approach
Systems diagnosis across patients, clinicians and policy, validated through a 12-hour bodystorming simulation and prototyping techniques like Wizard-of-Oz.
Systems diagnosis across patients, clinicians and policy, validated through a 12-hour bodystorming simulation and prototyping techniques like Wizard-of-Oz.
Systems diagnosis across patients, clinicians and policy, validated through a 12-hour bodystorming simulation and prototyping techniques like Wizard-of-Oz.
Result
Result
Result
Result
A bounded, non-clinical ecosystem that steps in where the healthcare system steps out, the first 30 days at home.
A bounded, non-clinical ecosystem that steps in where the healthcare system steps out, the first 30 days at home.
A bounded, non-clinical ecosystem that steps in where the healthcare system steps out, the first 30 days at home.
The Impact
The Impact
The Impact
The Impact
$52.4B
$52.4B
Annual cost of the problem
Annual cost of the problem
Annual cost of the problem
20%
20%
Projected readmission reduction
Projected readmission reduction
Projected readmission reduction
38% to 85%+
38% to 85%+
Follow-up appointment rate
Follow-up appointment rate
Follow-up appointment rate
N=9
N=9
Real patients tested
Real patients tested
Real patients tested
The Challenge
The Challenge
The Challenge
The highest risk in chronic care isn’t only clinical complexity it’s what happens when care transitions to the home without support.
The highest risk in chronic care isn’t only clinical complexity it’s what happens when care transitions to the home without support.
Scoping the Project
Started broad: People living chronic illness + living alone
Started broad: People living chronic illness + living alone
Found during research: Post-discharge is the highest-stakes window
Found during research: Post-discharge is the highest-stakes window
Narrowed to: Adults 65+ living alone, first 30 days post-discharge (patient harm + hospital penalty)
Narrowed to: Adults 65+ living alone, first 30 days post-discharge (patient harm + hospital penalty)
Focus Cohort
Focus Cohort
Adults 65+
Adults 65+
Recently Discharged
Recently Discharged
Heart Failure +/ Type 2 Diabetes
Heart Failure +/ Type 2 Diabetes
Living Alone
Living Alone
How I Identified the Problem
A trail from 'Inspiration' to a clear scope
The
Problem
Statement
The Problem Statement
In the U.S., adults over the age of 65 with a Heart condition and/or type 2 Diabetes who lack a regular in-home caregiver face a fragile first 30 days after hospital discharge:
In the U.S., adults over the age of 65 with a Heart condition and/or type 2 Diabetes who lack a regular in-home caregiver face a fragile first 30 days after hospital discharge:
they must secure meds, set up devices, spot warning signs, and make early follow-ups with fragmented support, which leads to confusion, missed care, and preventable ED returns.
they must secure meds, set up devices, spot warning signs, and make early follow-ups with fragmented support, which leads to confusion, missed care, and preventable ED returns.
Diagnosis & findings
Diagnosis & findings
Diagnosis & findings
I treated this project as a systems diagnosis to understand why continuity breaks after discharge for adults living alone, and where a service intervention could reduce preventable escalation.
I treated this project as a systems diagnosis to understand why continuity breaks after discharge for adults living alone, and where a service intervention could reduce preventable escalation.
The Hypothesis
The Hypothesis
Post-discharge breakdowns aren’t caused by low motivation they’re caused by unclear guidance and missing coordination at home.
Post-discharge breakdowns aren’t caused by low motivation they’re caused by unclear guidance and missing coordination at home.
Evidence
Collected
Stakeholder perspectives:
Patients + Clinicians + System constraints (Policy/Operations)
Stakeholder perspectives:
Patients + Clinicians + System constraints (Policy/Operations)
Pattern search:
Repeating breakdowns in the first 30 days (Symptoms, Meds, Follow-ups, Escalation)
Pattern search:
Repeating breakdowns in the first 30 days (Symptoms, Meds, Follow-ups, Escalation)
Online ethnography:
Caregiver + Patient communities to validate real-world friction
Online ethnography:
Caregiver + Patient communities to validate real-world friction
The chart below maps the patient’s emotional journey across the first 30 days post-discharge, plotted against the level of involvement from three support actors:
The chart below maps the patient’s emotional journey across the first 30 days post-discharge, plotted against the level of involvement from three support actors:
Hospital care teams
Hospital care teams
Pharmacies
Pharmacies
Society Support.
Society Support.
What this
Revealed
What this
Revealed
Care is front-loaded, then drops:
The patient becomes the coordinator by default.
Care is front-loaded, then drops:
The patient becomes the coordinator by default.
Pharmacy is recurring, not reassuring:
It can’t resolve “is this normal?” uncertainty.
Pharmacy is recurring, not reassuring:
It can’t resolve “is this normal?” uncertainty.
Community help is real but unreliable:
Support exists, but it isn’t integrated or guaranteed.
Community help is real but unreliable:
Support exists, but it isn’t integrated or guaranteed.
The Insight
The Insight
Post-discharge support is delivered in touchpoints, but recovery is lived in the in-between and that gap is where uncertainty compounds into avoidable escalation.
Post-discharge support is delivered in touchpoints, but recovery is lived in the in-between and that gap is where uncertainty compounds into avoidable escalation.
Design Implication
Design
Implication
Design must bridge the “between” moments with reassurance, coordination, and safe escalation.
Design must bridge the “between” moments with reassurance, coordination, and safe escalation.
To pressure-test these “in-between” moments, I ran a 12-hour informed body-storming simulation.
To pressure-test these “in-between” moments, I ran a 12-hour informed body-storming simulation.
*Note:
This was a non-clinical, self-run simulation to pressure-test coordination burden, not a substitute for patient's lived experience.
*Note:
This was a non-clinical, self-run simulation to pressure-test coordination burden, not a substitute for patient's lived experience.
The
Simulation
The
Simulation
Physical:
Reduced strength + Mobility using wearable weighted constraints, and localized sensitivity constraints to approximate recovery limits
Physical:
Reduced strength + Mobility using wearable weighted constraints, and localized sensitivity constraints to approximate recovery limits
Visual:
Simulated age-related vision loss to test readability of discharge instructions and medication packaging
Visual:
Simulated age-related vision loss to test readability of discharge instructions and medication packaging
Context:
Time-based grocery store errands and realistic artifacts to mirror how decisions occur at home
Context:
Time-based grocery store errands and realistic artifacts to mirror how decisions occur at home
What I experienced
What I experienced
Even routine tasks can become high-friction without support. Small barriers (legibility, mobility, logistics) compound into cognitive load making it harder to stay confident and decide what to do next.
Even routine tasks can become high-friction without support. Small barriers (legibility, mobility, logistics) compound into cognitive load making it harder to stay confident and decide what to do next.
Learnings
Learnings
This wasn’t a substitute for patient lived experience. It was a way to sense the gravity of being alone with recovery work and to identify where a service must reduce coordination burden and uncertainty in daily life.
This wasn’t a substitute for patient lived experience. It was a way to sense the gravity of being alone with recovery work and to identify where a service must reduce coordination burden and uncertainty in daily life.
Small breakdowns at home compound into avoidable escalation, and that’s what health systems pay for.
Small breakdowns at home compound into avoidable escalation, and that’s what health systems pay for.
Consequences of 30-day readmission (hospital/system impact)
Consequences of 30-day readmission (hospital/system impact)
Avoidable readmissions impact hospitals across three fronts:
Avoidable readmissions impact hospitals across three fronts:
Loss of Life
Loss of Life
Leads to 7 - 23% mortality rate depending upon the length of follow-up.
Leads to 7 - 23% mortality rate depending upon the length of follow-up.
Loss of Reputation
Loss of Reputation
Hospitals lose patient's trust and public ratings.
Hospitals lose patient's trust and public ratings.
Financial Penalties
Financial Penalties
~1% Deduction as penalty, reducing Medicare fee-for-service payments
~1% Deduction as penalty, reducing Medicare fee-for-service payments
While 1% Doesn't sound much, as of September 2025 this is a
While 1% Doesn't sound much, as of September 2025 this is a
Opportunity Space
Opportunity Space
Opportunity Space
Most post-discharge support is optimized for handoffs, not home. The gap is the first 30 days after discharge, when patients living alone need reassurance and coordination not more paperwork.
The Opportunity Strategy
My solution shifts the burden of the "Maintenance Beast" from the patient to a Passive Sensing Ecosystem. By combining a non-threatening companion robot with a community-driven volunteer network, we solve the Social Isolation root cause that clinical tools ignore.
Instead of competing with existing clinical tools, I identified a "Blue Ocean" in the Low-Acuity Home Space.
The Clinical Gap:
Existing solutions are too "medical" (fear-inducing) or too complex for a 65+ user under cognitive load.
The Untapped Opportunity
A lightweight support layer that helps patients reliably answer:
Is this normal?
What should I do today?
Who can help right now?
Opportunity pillars
Human
Reassurance
A trusted clarification + escalation pathway
Daily
Guidance
Translate discharge into simple routines
Community
Support
Enable small tasks like rides, refills, check-ins
30-day
focus
Designed for the post-discharge window
The
Opportunity
Statement
Translate discharge into simple daily routines, add a human reassurance line for non-emergencies, and activate nearby helpers for meds/food/rides closing clarity, capability, reassurance, and connection gaps.
The Solution
The Solution
The Solution
I designed a three-part support ecosystem for the first 30 days post-discharge that replaces key “caregiver functions” with a bounded, non-clinical service layer reducing uncertainty, coordination burden, and avoidable escalation.
I designed a three-part support ecosystem for the first 30 days post-discharge that replaces key “caregiver functions” with a bounded, non-clinical service layer reducing uncertainty, coordination burden, and avoidable escalation.
Replace the missing caregiver with:
Guidance (Kiko) + Reassurance (Medi-Mate) + Logistics help (Volunteers).
Replace the missing caregiver with:
Guidance (Kiko) + Reassurance (Medi-Mate) + Logistics help (Volunteers).
Medi-Mate (Non-clinical Hotline)
Medi-Mate (Non-clinical Hotline)
Medi-Mate (Non-clinical Hotline)
Answers “Is this normal?” safely:
Answers “Is this normal?” safely:
Reassurance + triage prompts
Next-step guidance
Links to discharge context
Kiko (robot companion):
Kiko (robot companion):
Turns discharge into a daily plan:
Turns discharge into a daily plan:
Today / Week / If-Then
meds + follow-ups
escalation cues
Volunteer Network (Community)
Volunteer Network (Community)
Volunteer Network (Community)
Makes practical support reliable:
Makes practical support reliable:
Rides / refills / check-ins
Optional, not dependency
Reduces isolation load
How it Works
Take care of yourself and Kiko stays happy, miss your medications or mess up your routine...he's going to be sad
Take care of yourself and Kiko stays happy, miss your medications or mess up your routine...he's going to be sad
Need a helping hand? The Volunteer Network is at your Service!
Need a helping hand? The Volunteer Network is at your Service!
Not sure if your symptoms need medical attention? No worries! The Medi-mate has it covered
Not sure if your symptoms need medical attention? No worries! The Medi-mate has it covered
A system to support, care and nourish
A system to support, care and nourish
Safety
Boundary
Safety Boundary
This ecosystem is designed as a non-clinical support layer. It does not diagnose or replace medical care; it supports clarity, coordination, and safe escalation.
This ecosystem is designed as a non-clinical support layer. It does not diagnose or replace medical care; it supports clarity, coordination, and safe escalation.
Value Proposition
Value Proposition
Value Proposition
A 30-day post-discharge continuity layer that reduces uncertainty + coordination burden for patients living alone while lowering avoidable escalation for health systems.
A 30-day post-discharge continuity layer that reduces uncertainty + coordination burden for patients living alone while lowering avoidable escalation for health systems.
For Patients
For Patients
Clarity, Confidence, Follow-through
Clarity, Confidence, Follow-through
For Hospitals
For Hospitals
For Hospitals
Fewer avoidable ED returns, Stronger continuity, Lower strain
Fewer avoidable ED returns, Stronger continuity, Lower strain
For Volunteers
For Volunteers
For Volunteers
Simple, safe tasks with recognition/credits; real impact.
Simple, safe tasks with recognition/credits; real impact.
Prototyping & Testing (Wizard-of-Oz)
Prototyping & Testing (Wizard-of-Oz)
I built & tested the support ecosystem through scenario-based prototyping and early feasibility checks.
I built & tested the support ecosystem through scenario-based prototyping and early feasibility checks.
Kiko
Medi-Mate
Volunteers
Hypothesis:
Voice guidance boosts clarity + independence when reading is hard.
The Test:
Today / Week / If–Then plan + meds + follow-ups.
Method:
Voice GPT prototype tested (N=9) with post-discharge scenarios.
Outcome:
Higher confidence + clearer next steps; voice removed “small text” friction.
Design
Changes
Design
Changes
Clearer escalation cues, lower cognitive load, volunteers positioned as logistics not safety-critical care.
Clearer escalation cues, lower cognitive load, volunteers positioned as logistics not safety-critical care.
Projected Impact & KPIs
Projected Impact & KPIs
Projected Impact & KPIs
0%
0%
Drop in 30-day readmissions
0%
0%
Reduced Unplanned ED Visits
0%
0%
Follow-up kept (7–14d)
0
0
Points Reduced on 10-pt Anxiety scale
Learnings & Reflection
Learnings & Reflection
Learnings & Reflection
Recovery breaks in the mundane: Daily-life friction compounds into risk when someone is alone.
Human reassurance is a feature (not a fallback); automation works best for clarity & navigation.
Community support must augment the safety net, not become the safety net.
Great one on one Mentorship
In-depth Prototyping
Battle Ground of FigJam
The Challenge
The highest risk in chronic care isn’t only clinical complexity it’s what happens when care transitions to the home without support.
Scoping the Project
Started broad: People living chronic illness + living alone
Found during research: Post-discharge is the highest-stakes window
Narrowed to: Adults 65+ living alone, first 30 days post-discharge (patient harm + hospital penalty)
Focus Cohort
Adults 65+
Recently Discharged
Heart Failure +/ Type 2 Diabetes
Living Alone
Living Alone
How I Identified the Problem
A trail from 'Inspiration' to a clear scope
The
Problem
Statement
In the U.S., adults over the age of 65 with a Heart condition and/or type 2 Diabetes who lack a regular in-home caregiver face a fragile first 30 days after hospital discharge:
they must secure meds, set up devices, spot warning signs, and make early follow-ups with fragmented support, which leads to confusion, missed care, and preventable ED returns.
Diagnosis & findings
I treated this project as a systems diagnosis to understand why continuity breaks after discharge for adults living alone, and where a service intervention could reduce preventable escalation.
The Hypothesis
Post-discharge breakdowns aren’t caused by low motivation they’re caused by unclear guidance and missing coordination at home.
Evidence
Collected
Stakeholder perspectives:
Patients + Clinicians + System constraints (Policy/Operations)
Pattern search:
Repeating breakdowns in the first 30 days (Symptoms, Meds, Follow-ups, Escalation)
Online ethnography:
Caregiver + Patient communities to validate real-world friction
The chart below maps the patient’s emotional journey across the first 30 days post-discharge, plotted against the level of involvement from three support actors:
Hospital care teams
Pharmacies
Society Support.
What this
Revealed
Care is front-loaded, then drops:
The patient becomes the coordinator by default.
Pharmacy is recurring, not reassuring:
It can’t resolve “is this normal?” uncertainty.
Community help is real but unreliable:
Support exists, but it isn’t integrated or guaranteed.
The Insight
Post-discharge support is delivered in touchpoints, but recovery is lived in the in-between and that gap is where uncertainty compounds into avoidable escalation.
Design Implication
Design must bridge the “between” moments with reassurance, coordination, and safe escalation.
To pressure-test these “in-between” moments, I ran a 12-hour informed body-storming simulation.
*Note:
This was a non-clinical, self-run simulation to pressure-test coordination burden, not a substitute for patient's lived experience.
The
Simulation
Physical:
Reduced strength + Mobility using wearable weighted constraints, and localized sensitivity constraints to approximate recovery limits
Visual:
Simulated age-related vision loss to test readability of discharge instructions and medication packaging
Context:
Time-based grocery store errands and realistic artifacts to mirror how decisions occur at home
What I experienced
Even routine tasks can become high-friction without support. Small barriers (legibility, mobility, logistics) compound into cognitive load making it harder to stay confident and decide what to do next.
Learnings
This wasn’t a substitute for patient lived experience. It was a way to sense the gravity of being alone with recovery work and to identify where a service must reduce coordination burden and uncertainty in daily life.
Small breakdowns at home compound into avoidable escalation, and that’s what health systems pay for.
Consequences of 30-day readmission (hospital/system impact)
Avoidable readmissions impact hospitals across three fronts:
Loss of Life
Leads to 7 - 23% mortality rate depending upon the length of follow-up.
Loss of Reputation
Hospitals lose patient's trust and public ratings.
Financial Penalties
~1% Deduction as penalty, reducing Medicare fee-for-service payments
While 1% Doesn't sound much, as of September 2025 this is a
Opportunity Space
Most post-discharge support is optimized for handoffs, not home. The gap is the first 30 days after discharge, when patients living alone need reassurance and coordination not more paperwork.
The Opportunity Strategy
My solution shifts the burden of the "Maintenance Beast" from the patient to a Passive Sensing Ecosystem. By combining a non-threatening companion robot with a community-driven volunteer network, we solve the Social Isolation root cause that clinical tools ignore.
Instead of competing with existing clinical tools, I identified a "Blue Ocean" in the Low-Acuity Home Space.
The Clinical Gap:
Existing solutions are too "medical" (fear-inducing) or too complex for a 65+ user under cognitive load.
The Untapped Opportunity
A lightweight support layer that helps patients reliably answer:
Is this normal?
What should I do today?
Who can help right now?
Opportunity pillars
Human
Reassurance
A trusted clarification + escalation pathway
Daily
Guidance
Translate discharge into simple routines
Community
Support
Enable small tasks like rides, refills, check-ins
30-day
focus
Designed for the post-discharge window
The
Opportunity
Statement
Translate discharge into simple daily routines, add a human reassurance line for non-emergencies, and activate nearby helpers for meds/food/rides closing clarity, capability, reassurance, and connection gaps.
The Solution
I designed a three-part support ecosystem for the first 30 days post-discharge that replaces key “caregiver functions” with a bounded, non-clinical service layer reducing uncertainty, coordination burden, and avoidable escalation.
Replace the missing caregiver with:
Guidance (Kiko) + Reassurance (Medi-Mate) + Logistics help (Volunteers).
Medi-Mate (Non-clinical Hotline)
Answers “Is this normal?” safely:
Reassurance + triage prompts
Next-step guidance
Links to discharge context
Kiko (robot companion):
Turns discharge into a daily plan:
Today / Week / If-Then
meds + follow-ups
escalation cues
Volunteer Network (Community)
Makes practical support reliable:
Rides / refills / check-ins
Optional, not dependency
Reduces isolation load
How it Works
Take care of yourself and Kiko stays happy, miss your medications or mess up your routine...he's going to be sad
Need a helping hand? The Volunteer Network is at your Service!
Not sure if your symptoms need medical attention? No worries! The Medi-mate has it covered
A system to support, care and nourish
Safety
Boundary
This ecosystem is designed as a non-clinical support layer. It does not diagnose or replace medical care; it supports clarity, coordination, and safe escalation.
Value Proposition
A 30-day post-discharge continuity layer that reduces uncertainty + coordination burden for patients living alone while lowering avoidable escalation for health systems.
For Patients
Clarity, Confidence, Follow-through
For Hospitals
Fewer avoidable ED returns, Stronger continuity, Lower strain
For Volunteers
Simple, safe tasks with recognition/credits; real impact.
Prototyping & Testing (Wizard-of-Oz)
I built & tested the support ecosystem through scenario-based prototyping and early feasibility checks.
Kiko
Medi-Mate
Volunteers
Hypothesis:
Voice guidance boosts clarity + independence when reading is hard.
The Test:
Today / Week / If–Then plan + meds + follow-ups.
Method:
Voice GPT prototype tested (N=9) with post-discharge scenarios.
Outcome:
Higher confidence + clearer next steps; voice removed “small text” friction.
Design
Changes
Clearer escalation cues, lower cognitive load, volunteers positioned as logistics not safety-critical care.
Projected Impact & KPIs
0%
0%
Drop in 30-day readmissions
0%
0%
Reduced Unplanned ED Visits
0%
0%
Follow-up kept (7–14d)
0
0
Points Reduced on 10-pt Anxiety scale
Learnings & Reflection
Recovery breaks in the mundane: Daily-life friction compounds into risk when someone is alone.
Human reassurance is a feature (not a fallback); automation works best for clarity & navigation.
Community support must augment the safety net, not become the safety net.
Great one on one Mentorship
In-depth Prototyping
Battle Ground of FigJam
The Challenge
The highest risk in chronic care isn’t only clinical complexity it’s what happens when care transitions to the home without support.
Scoping the Project
Started broad: People living chronic illness + living alone
Found during research: Post-discharge is the highest-stakes window
Narrowed to: Adults 65+ living alone, first 30 days post-discharge (patient harm + hospital penalty)
Focus Cohort
Adults 65+
Recently Discharged
Heart Failure +/ Type 2 Diabetes
Living Alone
Living Alone
How I Identified the Problem
A trail from 'Inspiration' to a clear scope
The
Problem
Statement
In the U.S., adults over the age of 65 with a Heart condition and/or type 2 Diabetes who lack a regular in-home caregiver face a fragile first 30 days after hospital discharge:
they must secure meds, set up devices, spot warning signs, and make early follow-ups with fragmented support, which leads to confusion, missed care, and preventable ED returns.
Diagnosis & findings
I treated this project as a systems diagnosis to understand why continuity breaks after discharge for adults living alone, and where a service intervention could reduce preventable escalation.
The Hypothesis
Post-discharge breakdowns aren’t caused by low motivation they’re caused by unclear guidance and missing coordination at home.
Evidence
Collected
Stakeholder perspectives:
Patients + Clinicians + System constraints (Policy/Operations)
Pattern search:
Repeating breakdowns in the first 30 days (Symptoms, Meds, Follow-ups, Escalation)
Online ethnography:
Caregiver + Patient communities to validate real-world friction
The chart below maps the patient’s emotional journey across the first 30 days post-discharge, plotted against the level of involvement from three support actors:
Hospital care teams
Pharmacies
Society Support.
What this
Revealed
Care is front-loaded, then drops:
The patient becomes the coordinator by default.
Pharmacy is recurring, not reassuring:
It can’t resolve “is this normal?” uncertainty.
Community help is real but unreliable:
Support exists, but it isn’t integrated or guaranteed.
The Insight
Post-discharge support is delivered in touchpoints, but recovery is lived in the in-between and that gap is where uncertainty compounds into avoidable escalation.
Design Implication
Design must bridge the “between” moments with reassurance, coordination, and safe escalation.
To pressure-test these “in-between” moments, I ran a 12-hour informed body-storming simulation.
*Note:
This was a non-clinical, self-run simulation to pressure-test coordination burden, not a substitute for patient's lived experience.
The
Simulation
Physical:
Reduced strength + Mobility using wearable weighted constraints, and localized sensitivity constraints to approximate recovery limits
Visual:
Simulated age-related vision loss to test readability of discharge instructions and medication packaging
Context:
Time-based grocery store errands and realistic artifacts to mirror how decisions occur at home
What I experienced
Even routine tasks can become high-friction without support. Small barriers (legibility, mobility, logistics) compound into cognitive load making it harder to stay confident and decide what to do next.
Learnings
This wasn’t a substitute for patient lived experience. It was a way to sense the gravity of being alone with recovery work and to identify where a service must reduce coordination burden and uncertainty in daily life.
Small breakdowns at home compound into avoidable escalation, and that’s what health systems pay for.
Consequences of 30-day readmission (hospital/system impact)
Avoidable readmissions impact hospitals across three fronts:
Loss of Life
Leads to 7 - 23% mortality rate depending upon the length of follow-up.
Loss of Reputation
Hospitals lose patient's trust and public ratings.
Financial Penalties
~1% Deduction as penalty, reducing Medicare fee-for-service payments
While 1% Doesn't sound much, as of September 2025 this is a
Opportunity Space
Most post-discharge support is optimized for handoffs, not home. The gap is the first 30 days after discharge, when patients living alone need reassurance and coordination not more paperwork.
The Opportunity Strategy
My solution shifts the burden of the "Maintenance Beast" from the patient to a Passive Sensing Ecosystem. By combining a non-threatening companion robot with a community-driven volunteer network, we solve the Social Isolation root cause that clinical tools ignore.
Instead of competing with existing clinical tools, I identified a "Blue Ocean" in the Low-Acuity Home Space.
The Clinical Gap:
Existing solutions are too "medical" (fear-inducing) or too complex for a 65+ user under cognitive load.
The Untapped Opportunity
A lightweight support layer that helps patients reliably answer:
Is this normal?
What should I do today?
Who can help right now?
Opportunity pillars
Human
Reassurance
A trusted clarification + escalation pathway
Daily
Guidance
Translate discharge into simple routines
Community
Support
Enable small tasks like rides, refills, check-ins
30-day
focus
Designed for the post-discharge window
The
Opportunity
Statement
Translate discharge into simple daily routines, add a human reassurance line for non-emergencies, and activate nearby helpers for meds/food/rides closing clarity, capability, reassurance, and connection gaps.
The Solution
I designed a three-part support ecosystem for the first 30 days post-discharge that replaces key “caregiver functions” with a bounded, non-clinical service layer reducing uncertainty, coordination burden, and avoidable escalation.
Replace the missing caregiver with:
Guidance (Kiko) + Reassurance (Medi-Mate) + Logistics help (Volunteers).
Medi-Mate (Non-clinical Hotline)
Answers “Is this normal?” safely:
Reassurance + triage prompts
Next-step guidance
Links to discharge context
Kiko (robot companion):
Turns discharge into a daily plan:
Today / Week / If-Then
meds + follow-ups
escalation cues
Volunteer Network (Community)
Makes practical support reliable:
Rides / refills / check-ins
Optional, not dependency
Reduces isolation load
How it Works
Take care of yourself and Kiko stays happy, miss your medications or mess up your routine...he's going to be sad
Need a helping hand? The Volunteer Network is at your Service!
Not sure if your symptoms need medical attention? No worries! The Medi-mate has it covered
A system to support, care and nourish
Safety Boundary
This ecosystem is designed as a non-clinical support layer. It does not diagnose or replace medical care; it supports clarity, coordination, and safe escalation.
Value Proposition
A 30-day post-discharge continuity layer that reduces uncertainty + coordination burden for patients living alone while lowering avoidable escalation for health systems.
For Patients
Clarity, Confidence, Follow-through
For Hospitals
Fewer avoidable ED returns, Stronger continuity, Lower strain
For Volunteers
Simple, safe tasks with recognition/credits; real impact.
Prototyping & Testing (Wizard-of-Oz)
I built & tested the support ecosystem through scenario-based prototyping and early feasibility checks.
Kiko
Medi-Mate
Volunteers
Hypothesis:
Voice guidance boosts clarity + independence when reading is hard.
The Test:
Today / Week / If–Then plan + meds + follow-ups.
Method:
Voice GPT prototype tested (N=9) with post-discharge scenarios.
Outcome:
Higher confidence + clearer next steps; voice removed “small text” friction.
Design Changes
Clearer escalation cues, lower cognitive load, volunteers positioned as logistics not safety-critical care.
Projected Impact & KPIs
0%
0%
Drop in 30-day readmissions
0%
0%
Reduced Unplanned ED Visits
0%
0%
Follow-up kept (7–14d)
0
0
Points Reduced on 10-pt Anxiety scale
Learnings & Reflection
Recovery breaks in the mundane: Daily-life friction compounds into risk when someone is alone.
Human reassurance is a feature (not a fallback); automation works best for clarity & navigation.
Community support must augment the safety net, not become the safety net.
Great one on one Mentorship
In-depth Prototyping
Battle Ground of FigJam
The Challenge
The highest risk in chronic care isn’t only clinical complexity it’s what happens when care transitions to the home without support.
Scoping the Project
Started broad: People living chronic illness + living alone
Found during research: Post-discharge is the highest-stakes window
Narrowed to: Adults 65+ living alone, first 30 days post-discharge (patient harm + hospital penalty)
Focus Cohort
Adults 65+
Recently Discharged
Heart Failure +/ Type 2 Diabetes
Living Alone
Living Alone
How I Identified the Problem
A trail from 'Inspiration' to a clear scope
The
Problem
Statement
In the U.S., adults over the age of 65 with a Heart condition and/or type 2 Diabetes who lack a regular in-home caregiver face a fragile first 30 days after hospital discharge:
they must secure meds, set up devices, spot warning signs, and make early follow-ups with fragmented support, which leads to confusion, missed care, and preventable ED returns.
Diagnosis & findings
I treated this project as a systems diagnosis to understand why continuity breaks after discharge for adults living alone, and where a service intervention could reduce preventable escalation.
The Hypothesis
Post-discharge breakdowns aren’t caused by low motivation they’re caused by unclear guidance and missing coordination at home.
Evidence
Collected
Stakeholder perspectives:
Patients + Clinicians + System constraints (Policy/Operations)
Pattern search:
Repeating breakdowns in the first 30 days (Symptoms, Meds, Follow-ups, Escalation)
Online ethnography:
Caregiver + Patient communities to validate real-world friction
The chart below maps the patient’s emotional journey across the first 30 days post-discharge, plotted against the level of involvement from three support actors:
Hospital care teams
Pharmacies
Society Support.
What this
Revealed
Care is front-loaded, then drops:
The patient becomes the coordinator by default.
Pharmacy is recurring, not reassuring:
It can’t resolve “is this normal?” uncertainty.
Community help is real but unreliable:
Support exists, but it isn’t integrated or guaranteed.
The Insight
Post-discharge support is delivered in touchpoints, but recovery is lived in the in-between and that gap is where uncertainty compounds into avoidable escalation.
Design Implication
Design must bridge the “between” moments with reassurance, coordination, and safe escalation.
To pressure-test these “in-between” moments, I ran a 12-hour informed body-storming simulation.
*Note:
This was a non-clinical, self-run simulation to pressure-test coordination burden, not a substitute for patient's lived experience.
The
Simulation
Physical:
Reduced strength + Mobility using wearable weighted constraints, and localized sensitivity constraints to approximate recovery limits
Visual:
Simulated age-related vision loss to test readability of discharge instructions and medication packaging
Context:
Time-based grocery store errands and realistic artifacts to mirror how decisions occur at home
What I experienced
Even routine tasks can become high-friction without support. Small barriers (legibility, mobility, logistics) compound into cognitive load making it harder to stay confident and decide what to do next.
Learnings
This wasn’t a substitute for patient lived experience. It was a way to sense the gravity of being alone with recovery work and to identify where a service must reduce coordination burden and uncertainty in daily life.
Small breakdowns at home compound into avoidable escalation, and that’s what health systems pay for.
Consequences of 30-day readmission (hospital/system impact)
Avoidable readmissions impact hospitals across three fronts:
Loss of Life
Leads to 7 - 23% mortality rate depending upon the length of follow-up.
Loss of Reputation
Hospitals lose patient's trust and public ratings.
Financial Penalties
~1% Deduction as penalty, reducing Medicare fee-for-service payments
While 1% Doesn't sound much, as of September 2025 this is a
Opportunity Space
Most post-discharge support is optimized for handoffs, not home. The gap is the first 30 days after discharge, when patients living alone need reassurance and coordination not more paperwork.
The Opportunity Strategy
My solution shifts the burden of the "Maintenance Beast" from the patient to a Passive Sensing Ecosystem. By combining a non-threatening companion robot with a community-driven volunteer network, we solve the Social Isolation root cause that clinical tools ignore.
Instead of competing with existing clinical tools, I identified a "Blue Ocean" in the Low-Acuity Home Space.
The Clinical Gap:
Existing solutions are too "medical" (fear-inducing) or too complex for a 65+ user under cognitive load.
The Untapped Opportunity
A lightweight support layer that helps patients reliably answer:
Is this normal?
What should I do today?
Who can help right now?
Opportunity pillars
Human Reassurance
A trusted clarification + escalation pathway
Daily Guidance
Translate discharge into simple routines
Community Support
Enable small tasks like rides, refills, check-ins
30-day focus
Designed for the post-discharge window
The
Opportunity
Statement
Translate discharge into simple daily routines, add a human reassurance line for non-emergencies, and activate nearby helpers for meds/food/rides closing clarity, capability, reassurance, and connection gaps.
The Solution
I designed a three-part support ecosystem for the first 30 days post-discharge that replaces key “caregiver functions” with a bounded, non-clinical service layer reducing uncertainty, coordination burden, and avoidable escalation.
Replace the missing caregiver with:
Guidance (Kiko) + Reassurance (Medi-Mate) + Logistics help (Volunteers).
Medi-Mate (Non-clinical Hotline)
Answers “Is this normal?” safely:
Reassurance + triage prompts
Next-step guidance
Links to discharge context
Kiko (robot companion):
Turns discharge into a daily plan:
Today / Week / If-Then
meds + follow-ups
escalation cues
Volunteer Network (Community)
Makes practical support reliable:
Rides / refills / check-ins
Optional, not dependency
Reduces isolation load
How it Works
Take care of yourself and Kiko stays happy, miss your medications or mess up your routine...he's going to be sad
Need a helping hand? The Volunteer Network is at your Service!
Not sure if your symptoms need medical attention? No worries! The Medi-mate has it covered
A system to support, care and nourish
Safety
Boundary
This ecosystem is designed as a non-clinical support layer. It does not diagnose or replace medical care; it supports clarity, coordination, and safe escalation.
Value Proposition
A 30-day post-discharge continuity layer that reduces uncertainty + coordination burden for patients living alone while lowering avoidable escalation for health systems.
For Patients
Clarity, Confidence, Follow-through
For Hospitals
Fewer avoidable ED returns, Stronger continuity, Lower strain
For Volunteers
Simple, safe tasks with recognition/credits; real impact.
Prototyping & Testing (Wizard-of-Oz)
I built & tested the support ecosystem through scenario-based prototyping and early feasibility checks.
Kiko
Medi-Mate
Volunteers
Hypothesis:
Voice guidance boosts clarity + independence when reading is hard.
The Test:
Today / Week / If–Then plan + meds + follow-ups.
Method:
Voice GPT prototype tested (N=9) with post-discharge scenarios.
Outcome:
Higher confidence + clearer next steps; voice removed “small text” friction.
Design Changes
Clearer escalation cues, lower cognitive load, volunteers positioned as logistics not safety-critical care.
Projected Impact & KPIs
0%
0%
Drop in 30-day readmissions
0%
0%
Reduced Unplanned ED Visits
0%
0%
Follow-up kept (7–14d)
0
0
Points Reduced on 10-pt Anxiety scale
Learnings & Reflection
Recovery breaks in the mundane: Daily-life friction compounds into risk when someone is alone.
Human reassurance is a feature (not a fallback); automation works best for clarity & navigation.
Community support must augment the safety net, not become the safety net.
Great one on one Mentorship
In-depth Prototyping
Battle Ground of FigJam
Back to top
Back to top
Back to top
Opportunity Space
Blue Ocean Strategy
Emotional engagement (Tamagotchi-like feedback) + human reassurance + community action.
First-30-days focus, not generic aging tech.
Nonprofit ethos with measured clinical and social outcomes.
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