Service
Design
Designing & iterating on a "Transitions of Care" service
Problem to Solve
Hospital admissions are one of the highest-cost, highest-risk moments in a member's care journey. After a hospitalization, Homeward members often do not have the support needed to recover safely at home, navigate post-discharge complexity, and avoid returning to the hospital. Without a structured transitions of care service, Homeward was missing a critical intervention window and losing the opportunity to build lasting longitudinal relationships with members at their most vulnerable.
​
The Goal
Design a Transitions of Care service that reliably engages members after a hospitalization, providing the support needed to ensure smooth recovery at home, reduce the risk of readmission, and create a clear pathway into ongoing preventative care with Homeward.
My Role
As Lead Service Designer, I owned the end-to-end design of Homeward's Transitions of Care service from the ground up. I partnered closely with clinical operations, product, and our care teams to define the service model, design the member and staff experience, and identify opportunities for future iterations.
My Role:
Lead Service Designer
Methods: ​
-
Service Blueprinting
-
Staff Shadowing & Research
-
Capability Identification & Prioritization
-
Member interviews
-
Engagement call listening
-
Insight synthesis
Tools: ​
-
Figjam
-
Google Slides
The Impact
The Transitions of Care service became Homeward's most effective entry point into longitudinal care. Across the program, we engaged approximately 18% of Homeward's total membership through this service alone. Members who came through Transitions of Care scheduled follow-up visits at a rate of 38%, compared to 25% across other entry points, demonstrating that meeting members at their most vulnerable moment was the most reliable way to build trust and convert episodic engagement into an ongoing care relationship with Homeward.
​
This service performed so well, we created another service called "ED Follow Up," where we replicated this service for the moment after a member's discharge from the emergency room.
The Process: The First Launch
Working closely with my cross-functional team, I designed the first version of the service across four key areas:
​
-
Visit cadence: Defined the frequency and structure of post-discharge visits with the clinical team to ensure members received timely, appropriate follow-up
-
Outreach script: Built the member-facing outreach script with the engagement team to ensure consistent, high-quality first contact after discharge
-
ADT notifications & Details: Surfaced the member admission details within tasks to support RNs and CES team members.
-
Steward workflow: Built the end-to-end workflow within Steward that care teams used to trigger and execute the service
A key outcome of the first launch was integrating engagement specialists into the workflow for the first time, creating smoother handoffs between the engagement team and our RNs and reducing gaps in member follow-through. The goal with this launch was to build an MVP to quickly learn & iterate for next versions.
Iterations: Second Launch
After the first version launched, I conducted an in-depth service review — listening to engagement calls, shadowing ToC visits, and analyzing drop-off points across the outreach and scheduling workflow. This surfaced four key opportunities that shaped the second launch.
​
Key Improvements Implemented:
-
Updated Outreach Methods: We were reaching members while still admitted, creating friction and low pickup rates. We shifted to SMS during admission and reserved calls for after discharge when members were home and more receptive.
-
AI-Generated Member Snapshots: Engagement specialists lacked enough context to have meaningful outreach conversations. We designed a richer member snapshot surfacing admit details, behavioral segment, and AI-generated talking points to help specialists lead with empathy and relevance from the first call.
-
Hospital Partnerships: We identified high-volume discharge hospitals and sent navigators on-site to strengthen relationships with hospital staff, helping members understand Homeward's value before discharge and improving the quality of handoffs into our service.
-
Clearer Post-Program Visit Guidance: RNs frequently didn't know what visit to schedule after ToC ended, creating gaps in longitudinal follow-through. We developed clear guidance mapping recommended visit types to member needs, ensuring a consistent transition into ongoing care.
​
I surfaced these opportunities to all the cross-functional stakeholders through detailed presentations to gain their buy-in for the improvements suggested and to begin their implementation.
ToC Vision Service Blueprint
With opportunities identified and sequenced into a roadmap, I designed a north star service blueprint representing the full vision of the Transitions of Care service. I mapped the end-to-end member experience alongside the backstage staff workflows, system touch-points, and handoffs needed to deliver it. This blueprint served as a shared reference point across clinical, operations, and product teams, grounding each iteration in a consistent vision and ensuring every improvement moved us deliberately toward the same destination.
My Learnings ​
The most important lesson was the value of launching lean. Getting a minimal version of the service in front of real members and care teams generated quick learnings that no amount of upfront design could replicate, surfacing improvements like outreach timing and member context that we wouldn't have caught otherwise.
​
However, launching lean only works with a clear north star vision to return to. The service blueprint kept the team anchored on where we were headed as we responded to early signal. Balancing nimbleness with a consistent vision was the core tension of this project, and one I'd carry into every service design engagement going forward.