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Hospital-to-home execution layer for heart-failure transitions

The discharge plan should not end at the hospital door.

Cairava converts each hospital-approved discharge plan into a shared, adaptive 30-day workflow, helps patients and caregivers complete the plan, and directs clinicians toward unresolved clinical, medication, scheduling, and social barriers.

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30 daysOne visible transition episode
Days 0–14Intensive follow-through
Human ownedEvery clinical decision
Built for independent and small-system community hospitals +A 30-day heart-failure transition episode, with optional step-down support +No devices, mandatory app, or major interface project required +Adaptive execution with human-owned clinical decisions +

The transition gap

Discharge is an event.
Recovery is a workflow.

Hospitals are held accountable for what happens after discharge—but follow-through still runs on paper packets, phone tag, and spreadsheets. The patient walks into a maze. The care team finds out when a loop breaks.

Cairava is the execution layer between what the EHR says should happen and what actually happens at home—without asking a 25-to-150-bed hospital to become a software implementation company.

41% of heart-failure patients leave the hospital with no follow-up scheduled within seven days · GWTG-HF registry, 569 US hospitals · View source ↗

One coordinated arc

One plan. Two connected experiences. Thirty visible days.

The patient sees clear next steps. The care team sees the exceptions. Cairava keeps both sides connected to the same hospital-approved transition workflow.

01

Discharge becomes a plan

Turn the handoff into clear, trackable work.

Cairava converts the approved discharge plan into transition obligations with an action, owner, deadline, state, evidence, barrier, and escalation path.

  • Structured from discharge documents or a quick-add fallback
  • Plain-language tasks with visible owners and due windows
  • A 30-day heart-failure episode with intensive support during days 0–14
Discharge becomes a plan
Transition planDay 1 of 30
Most important nextSchedule follow-upTarget window · within 7 days
✓Discharge plan organizedDone
2Medication access checkToday
02

Patients keep moving

Make follow-through easier at home.

Patients and caregivers receive timely, privacy-conscious guidance through text, mobile web, and optional native experiences. They can confirm progress, report a barrier, prepare questions, and see what comes next without another enrollment gate.

  • No mandatory app or new device to learn
  • Communication timing and wording adapt around the approved plan
  • A persistent plan patients can carry into follow-up
Patients keep moving
CairavaPrivate message
Good morning, Joan. Were you able to pick up the two new medicines on your hospital list?
I got one. The other was too expensive.
Barrier shared with the transition team
Type a replySend
03

Staff see the exceptions

Put limited clinical time where it matters.

The care team works from an exception queue instead of another undifferentiated call list. Unresolved clinical, medication, scheduling, and social barriers become visible with an owner and response window.

  • Prioritized, auditable exception management
  • Hospital-approved escalation paths
  • Operational reporting on loop closure and staff workload
Staff see the exceptions
Transition queue3 need review
AllMedicationFollow-up
Medication access barrierDay 2 · Cost reported
Review
Follow-up not scheduledDay 5 · Second reminder sent
Review
Caregiver requested helpDay 8 · Transportation
Review
A nurse and an older patient reviewing information together at home.
Built for the handoffHospital clarity. Human follow-through.

Built to fit

A community-hospital execution layer, not another enterprise platform.

Cairava is a focused execution layer for teams that need more reliable transition follow-through without a major systems project.

01

Launch in stages

Start with a contained, hospital-approved workflow rather than a multiyear transformation.

02

Work alongside the EHR

The EHR remains the clinical source of truth while Cairava coordinates execution and closed-loop follow-through.

03

Meet patients where they are

Text and mobile web make the workflow accessible without an app-store requirement or connected device.

04

Start focused

A hospital-approved heart-failure pathway creates a practical first deployment and a repeatable model for future conditions.

Clinical boundaries

Automation prepares the work. People own clinical decisions.

AI makes the workflow easier to understand and operate. Hospital-approved rules route concerns, and licensed care teams retain control of clinical decisions.

Cairava adapts how the approved plan is executed, while hospital-approved rules and licensed care teams retain control of clinical decisions. Every rule, handoff, owner, and resolution remains reviewable in the audit trail.

0 diagnoses · 0 dose changes· 0 AI-only clinical decisions—by design

Cairava does

Explain the hospital-approved plan in plain language

Track transition obligations, evidence, barriers, and closure state

Adapt communication and task sequencing around the approved plan

Apply hospital-approved routing and response rules

Surface unresolved barriers for accountable human reviewA person owns clinical interpretation and resolution

Status: runs automatically · every event logged

Cairava does not

Diagnose a patient or recommend treatment

Change a medication or suggest a dose

Independently set severity, thresholds, or clinical routing rules

Rewrite the approved plan or replace the EHR, care manager, or clinician

Status: owned by your clinicians

First design partnership

Help shape the transition program your hospital needs.

Cairava is preparing its first paid design partnership with an independent or small-system community hospital. The right partner has a visible heart-failure transition gap, a committed nursing or quality sponsor, and a preference for measuring transition-task closure and staff capacity before making downstream outcome claims.

Explore the working prototype Check partner fit

“No patient should have to navigate the most vulnerable days after a hospitalization alone.”

Why Cairava

Built from the work of closing these loops by hand.

Cairava grows from six years of cardiovascular research and care coordination experience—watching follow-up, medication, and access problems emerge between hospital and home, then helping patients and clinicians resolve them one call at a time.

See the workflow together

Bring the transition gap your team sees today.

Explore the working product, review the clinical boundary, and decide whether a focused design partnership fits your hospital.

Request a walkthrough Open the live prototype