When we began launching a post-discharge support program designed to help patients understand their discharge instructions, navigate care at home, and avoid unnecessary readmissions, it became clear almost immediately that we couldn’t design it well from a distance.

This was our first time building a program like this alongside a large, high-acuity hospital system. We started with an intentionally lightweight design, knowing the real work would be learning how discharge actually functions in practice.

But staying remote was limiting that learning.

To design something that worked inside a hospital, we needed to be there, observing daily workflows and understanding the real constraints clinicians, patients, and caregivers navigate every day.

So I went onsite with our CEO and Chief of Healthcare Partnerships to do field research. We wanted to see how discharge actually happens, talk with patients, caregivers, and staff in context, and understand where our assumptions held up and where they broke.

The Referral Model We Designed on Paper

Before going onsite, our mental model for the referral process was clean and logical: a case manager would identify an eligible patient, explain the program, and submit the referral.

In theory, it was simple. But in practice, we weren’t seeing the referral volume or conversion we expected. That signaled a deeper issue in the flow itself.

We asked ourselves: Where was it breaking down?

• How did case managers actually identify eligibility within their day-to-day workflows?
• What did submitting a referral really look like inside Epic, including friction, time required, and cognitive load?
• How was the program introduced to patients, how was value communicated, and how did patients actually react in that moment?
• What state of mind were patients in while hospitalized and at discharge, what messages resonated, and where did gaps in care show up?
• What did caregivers truly need in that moment, and what would it take to earn their trust and buy-in?

We couldn’t answer any of this from a distance.

Where the Referral Model Collapsed in Practice

The first day we arrived at the hospital, one thing became immediately clear: what we were seeing wasn’t a simple bottleneck. It was a structural imbalance.

Case managers were responsible for completing telling the patient about Starlight and making the referral. The problem was that patients assigned a case manager were, by definition, already surrounded by support. They only interacted with the top 20% most complex cases.

As I interviewed patients throughout their hospital stay, I started to see the support landscape around them more clearly. Many were being discharged to skilled nursing facilities. Others had home health services in place or deeply involved caregivers. One patient I spoke with had 8 different family members rotating throughout the day to make sure he was never alone.

These patients were complex, high risk, and absolutely deserving of attention.
But they were not unsupported.

Meanwhile, the remaining 80% of patients weren’t interacting with a case manager at all. They were still going home with medication changes, follow-up appointments, and discharge instructions they might not fully understand. Once they left the hospital, there was often no one proactively checking in.

These patients didn’t need intensive, ongoing care. Most would recover just fine. But when questions came up, and they often did, there was no clear place to get real-time guidance on which symptoms needed attention, how to handle medication changes, or how to stay on track with follow-up appointments. Small gaps like these are often what turn manageable recoveries into avoidable readmissions.

That gap is where the opportunity really was.

Designing for Patient Readiness

Spending time on the floor made me realize how chaotic the discharge process actually is. One patient I was interviewing was interrupted constantly.

A doctor came in. Then a nurse. Then a case manager. Then someone changing the bedpan.

There was very little uninterrupted mental space to process anything new.

Discharge nurses were well aware of this reality. They told us they do their best to emphasize the most important parts of discharge paperwork, but they also know much of it doesn’t stick.

Patients are being asked to absorb critical information at the exact moment they are least able to learn. Not because anyone is doing a poor job, but because the system optimizes for completion, not retention.

As we spent more time onsite, we discovered the discharge lounge, where patients waited after being formally discharged and before being picked up. The discharge lounge manager told us she is often asked to re-review discharge paperwork, especially when it comes to medication changes like new prescriptions, stopped meds, or adjusted doses layered on top of already complex regimens.

That validated a core assumption behind our program. Patients do need support to follow discharge instructions. But timing mattered far more than we initially realized.

The discharge lounge wasn’t just a waiting area. It was a moment of readiness. Patients were calmer. They were asking questions. They were actively trying to understand what came next.

The discharge lounge manager interacted with patients across all levels of complexity and told us she would want a way to refer patients to Starlight directly from the lounge. It felt like a natural fallback. A way to connect patients to support when referrals hadn’t already happened upstream.

That reframed our thinking entirely. The question was never whether patients needed support. They did. The real question was who needed it right away, and who would need it later, once the rest of the scaffolding fell away.

And that’s something we never would have learned without being there in person.

Caregivers as Decision-Makers, Not Blockers

Before going onsite, we already knew caregivers played a decisive role. In our early outreach, they were often the ones answering the phone, influencing or making the decision for the patient, and declining support on their behalf. We also believed they were carrying much of the post-discharge burden and would benefit from clearer guidance and clinical backup.

What we didn’t fully understand was why they so often said no.

Spending time with families made it clearer. Caregivers frequently managed discharge paperwork and medications, but they didn’t have a reliable place to go when questions inevitably came up. When a new symptom appeared, they were left deciding whether to wait, call someone, or go straight to urgent care or the ER. These decisions often happened late at night, when anxiety was high and options felt limited.

At the same time, illness was affecting entire families. I watched families process diagnoses at different speeds. In some cases, family members disagreed about who should receive information or how care decisions should be made. That tension showed up in ways that directly affected the patient.

What initially sounded like confidence was often self-protection. Caregivers weren’t blocking access. They were absorbing uncertainty, emotional labor, and clinical risk that the system quietly shifted onto them.

That raised a deeper question for us. Maybe caregivers didn’t just need better instructions or a clinical guide. In some cases, they needed help navigating family dynamics, emotional strain, and decision-making under stress. It made us ask whether post-discharge support should sometimes include licensed clinical social work, not just to support the patient, but to support the family system around them.

How Field Research Changed the Program Design

We used what we learned onsite to reshape both the program and the product.

• We treated timing as a core product decision, building the ability to assess existing support, intentionally snooze patients who were already covered, and re-engage when our support would actually be additive.
• We deprioritized heavy optimization of the case manager workflow, and instead partnered with hospital staff to identify new referral moments and in-hospital roles that could reach patients case managers never touched.
• We redesigned marketing and outreach for the hospital environment, using QR-based flyers with short videos that patients or caregivers could watch while inpatient. This standardized how the program was introduced, improved clarity and receptivity, and reduced reliance on clinical staff to explain the program.
• We added a 24-hour nurse line as a direct response to caregiver needs, giving patients and families a real human to call when something felt off instead of forcing them to make clinical judgment calls alone.
• We’re actively exploring incorporating licensed clinical social work to support patients and families navigating emotional strain, family dynamics, or complex caregiving decisions after discharge.

Being onsite also helped us spot opportunities we never would have seen remotely… and just as importantly, it built familiarity. By the time we finally launched our expansion plan across the hospital, staff already knew who we were and what we did. That recognition made change management and onboarding loads easier.

Field Research as a Go-to-Market Requirement

Seeing the hospital in person helped us understand the experience from multiple angles at once: what discharge feels like for patients, what decision-making looks like for caregivers, and what constraints clinicians are operating under minute to minute. That clarity revealed new opportunities inside the hospital itself… moments, roles, and touchpoints where support could be introduced more naturally and with far less friction.

This experience made something obvious: you can’t design effectively for a hospital system unless you see it from the inside.

Field research is the #1 best way to design programs that truly connect the virtual and the physical into a single, coherent experience.