Building a patient’s non-clinical care team post-discharge

3 minute read

Building a patient’s non-clinical care team post-discharge

< 1 minute read

St. Mary’s identifies a patient’s non-hospital care team of family, friends, and hired help—then works with them to develop a care plan.

The Issue

We provide our patients with a lot of information on what they need to do when they get home and how to ensure they stay healthy. The challenge is that it’s not always clear who to have these conversations with. Sometimes it’s the patient themselves if they’re physically and cognitively able to take care of themselves. Other times it’s a family member, a hired caregiver, or even a neighbor or roommate. Often, it’s a combination of these. One person is responsible for managing the patient’s medications, someone else helps with preparing meals and shopping, and someone else provides transportation to follow up appointments. To make it even more complicated, the person the patient wants to be their caregiver isn’t always willing or able to help.


St. Mary’s Medical Center is a non-profit teaching hospital in San Francisco, CA. It has 300 beds and serves a primarily elderly Medicare population with multiple comorbidities. Their transitions program began in 2009 and is influenced by Project RED and IHI’s Transforming Care at the Bedside.

What We Tried

We spend a lot of time talking with patients to understand what their caregiver situation is. We ask them a lot of basic questions about their life, like “Who lives with you? What do you eat? Who gives you your medications?” That information helps paint a picture of the patient’s entire care team and their different roles. When patients aren’t able to answer, we look around the room to see who is paying attention, taking notes, or asking questions. They can likely help us figure out who the care team is.

Once we identify the care team we direct information to the relevant person. We can’t expect one person to digest it all. So. For example, we’ll talk to the daughter about medications and the husband about dietary needs. We work with the care team to create a plan that works well for the patient and the caregivers’ lives.

Sometimes we find that the caregivers are overwhelmed but they feel bad about sending the patient to a SNF or bringing in home health. In those cases we can help be the mediator, explaining to the patient all the support they need and recommending that they find more sources of help.


These conversations help us get a better picture of a patient’s situation. Each caregiver will have different concerns and ask different questions based on what they help the patient with. By talking to all of them we can help ensure the patient is getting the best care possible and reduce the chances of readmission.


Figuring out who the caregivers are isn’t hard, but we have to really take the time to listen to the patient and everyone in the room with them. Even the paid caregivers are important to talk to.

We make sure to share everything we learn about the patient’s situation with their care team at the hospital because they rarely have the time to sit with the patient and learn these things themselves.

Organizational Background

Organization Name: St. Mary's Medical Center

Location: 450 Stanyan Street, San Francisco, CA, United States

Organization Type: Hospital