Strive Health Publishes Research in the ‘Journal of Patient Experience’

When a patient with chronic kidney disease (CKD) leaves the hospital, the journey is far from over. The weeks that follow are often filled with uncertainty, from managing medications and scheduling follow-up appointments to adapting to daily life after a health scare. These transitions can be overwhelming without the right support, and for too many, they result in a hospital readmission. 

That’s why transitional care matters.  

At Strive, we’ve seen firsthand how a structured, patient-centered approach can change the trajectory for patients living with advanced chronic conditions. Now, those results have been validated in the “Journal of Patient Experience,” where our Transitional Care Management (TCM) program is featured in “Link From Hospital to Home: Ensuring Quality Transitions for CKD Patients.” This new research highlights how Strive’s patient-centered approach helps those living with CKD navigate one of the most vulnerable moments in their care journey: the transition from hospital to home. 

Patients with CKD face significantly higher hospital readmission rates than the national all-hospital 30-day rate. According to the National Institute of Diabetes and Digestive and Kidney Diseases, 21.7% of CKD patients are readmitted to the hospital within 30 days of discharge, compared to the overall national readmission rate of 14.6%. Many of these readmissions are preventable, often stemming from gaps in discharge planning, medication confusion or lack of follow-up. Transitional care is designed to bridge those gaps by providing the education, coordination and support patients need to recover safely at home. 

Strive Research Findings 

Strive’s TCM program was created to support patients at moderate or high risk for readmission through a structured, multidisciplinary care model. Our team, including RN care managers, nurse practitioners, licensed social workers, dietitians, medical directors and care coordinators, provides proactive outreach, education and follow-up during the critical 30 days after discharge. 

The study found that patients with CKD enrolled in the program experienced significantly fewer hospital readmissions than those who declined enrollment. 

These results demonstrate the power of early intervention and ongoing support. By engaging patients quickly after discharge, addressing social and clinical needs and ensuring follow-up appointments, our TCM team helps patients avoid complications and stay on the path to better health. 

Implications for the Industry 

This study reinforces what many healthcare leaders already suspect: comprehensive, patient-centered transitional care is essential for populations with advanced chronic conditions. When designed thoughtfully and integrated into value-based care models, TCM programs can reduce unnecessary utilization, improve patient experience and strengthen overall care outcomes. Transitional care is not simply a “nice to have,” it’s a proven lever for improving outcomes and lowering costs. 

Strive celebrates this publication as a testament to the dedication of our clinical and care management teams, as well as to the authors of the publication, whose work demonstrates the measurable impact of transitional care. 

Strive Authors: 

• Emily Simon, BS | Program Manager 

• Melissa Feeney, PhD | Sr. Data Scientist 

• Joan Mendenhall, MS, BSN, RN CCM | VP, Clinical Services 

• Caroline Ruff, BSN, RN CCM | Sr. Director, Transition of Care 

• Tammy Cheung, MSc | Sr. Director, Data Science 

• Farhad Modarai, DO | Chief Clinical Officer 

• Muhammad Sohaib, MD, MBA, FACP | Medical Director 

Together, these Strivers are setting a new standard for supporting patients after hospitalization and showing the industry what’s possible when care is truly patient-centered. 

We hope you’ll explore the study in full, here.