REDUCE PREVENTABLE HEALTHCARE UTILIZATION
KokuaNet for Hospitals: From Referral to Resolution
Your teams work tirelessly from diagnosis to discharge, but what happens to patients after they leave? Hospitals face increasing pressure to reduce readmissions and manage costs, yet recovery can falter due to unstable housing, limited food access, unreliable transportation, and lack of social support. These social determinants of health (SDOH) not only impact quality of life but also significantly influence health outcomes and costs. At KokuaNet, we help hospitals bridge the gap between clinical care and everyday life. Our solutions address the social and environmental barriers affecting recovery, ensuring patients continue to progress after discharge.
Readmissions Penalties
In 2023, the Centers for Medicare & Medicaid Services (CMS) penalized over 2,200 hospitals, totaling more than $320 million in readmission penalties (KFF Health News, 2023). Patients with three or more Social Determinants of Health (SDOH) risk factors are twice as likely to be readmitted within 30 days of discharge, according to findings published in JAMA Network Open (BMJ Open, 2022).
Associated with Unmet Social Needs
One in three emergency room (ER) visits is associated with unmet social needs (Health Affairs, 2020). Patients lacking access to transportation or food are 50% more likely to visit the emergency department unnecessarily (CDC SDOH Brief, 2024).
Processes to Assess SDOH
Discharging patients to their homes without addressing social barriers can lead to worse health outcomes. Currently, only 34% of hospitals have a standardized process to assess SDOH before discharge (AHA, 2020).
Burnout Related to SDOH
Nurses and case managers spend up to 20% of their time managing social barriers instead of focusing on clinical work. Additionally, 56% of care managers report experiencing burnout due to inadequate support for addressing SDOH, according to the HealthLeaders 2025 Care Management Survey (HealthLeaders Media).
YOUR CHALLENGES, SOLVED WITH KOKUANET
We Help Hospitals Streamlining SDOH Care—Without Extra Workload
KokuaNet serves as an extension of your discharge team, helping you provide comprehensive care that continues beyond your facility. Let’s work together to reduce avoidable readmissions, enhance patient recovery, and equip your staff with the necessary tools to integrate SDOH into patient care without increasing their workload.
Timeline
Example Patient Journey Timeline
Name: Maria T.
Age: 66
Primary Diagnosis: Congestive Heart Failure
Insurance: Medicaid + Medicare Dual Eligible
Social Context: Lives alone, has limited mobility, recently lost a spouse, lacks a car, and struggles with nutrition.
SEE THE VALUE OF CLOSING GAPS IN REAL TIME
KokuaNet: Cost vs Benefit Calculator for Hospitals
Our interactive calculator helps hospitals estimate the impact and value of closing social needs gaps using KokuaNet’s closed-loop referral system. By entering your total annual discharges, percentage of patients screened for social needs, and an average number of social needs, the tool estimates your total program cost using our pay-for-performance model. It then calculates projected healthcare savings — based on avoided ER visits, hospitalizations, and other costly outcomes — to show your net benefit and return on impact. It’s a clear, data-backed way to see how verified gap closure improves health outcomes and your bottom line.
A smarter way to measure impact. This interactive calculator estimates your hospital’s ROI by comparing program costs with savings from reduced ER visits, readmissions, and other avoidable outcomes
Estimated Results include
- Projected KokuaNet program costs based on patient needs and service levels
- Estimated cost avoidance driven by fewer emergency department visits and preventable readmissions
- Quantified patient impact measured by identifying and addressing care gaps | Improvements in health equity tied to resolved gaps across zip codes and populations
- Net value shows total savings after accounting for program costs.
This calculator provides estimates only and does not represent a formal quote or guaranteed pricing.
Get in Touch
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Pricing
Performance Based Pricing
We ONLY bill when the result is REAL
Low Risk Employee
$100/ Gap Closed
- Risk based on SDOH acuity
- Local CBO Match
- Service Date Confirmed
- Service Verified
Medium Risk Employee
$150/ Gap Closed
- Risk based on SDOH Acuity
- Local CBO Match
- Service Data Confirmed
- Service Verified
Premium
$200/ Gap Closed
- High Risk Patient
- Local CBO Match
- Service Date Confrimed
- Service Verified
