Embedding post-discharge care into patient care plans

2 minute read

Embedding post-discharge care into patient care plans

< 1 minute read

Marin General presents post-discharge coaching as part of a patient’s care plan rather than as an optional service requiring consent.

The Issue

We had trouble getting patients to accept post-discharge coaching and home visits. There were a few reasons for this. The first was that we presented them with a one-page consent form that made them feel like they were signing up for something experimental. Secondly, presenting the program as something they were selected to participate in made it seem like there was an implicit weakness in the patient or their family and they needed extra help. Lastly, we originally had community health coaches present the program to patients and they weren’t comfortable enough in the hospital setting to exude a sense of confidence when speaking to patients.


Marin General is a non-profit hospital in Greenbrae, CA. It has 250 beds and serves a mainly affluent suburban/rural population with pockets of low-income Latinos, African-Americans, and state prison inmates. Their transitions program began in 2011 and is influenced by the Care Transitions Program and Project RED.

What We Tried

We reframed how we talk to patients about the program. Instead of asking for their consent, we say “This is what your physicians and care team recommend for you.” Since the majority of the coaching is offered by staff from the Accountable Care Organization, their affiliation with the primary care physician makes patient consent almost universal.

We also utilize the Patient Activation Measure to focus in on which patients to offer post-discharge coaching and home visits to. We concluded that the most activated patients likely didn’t need coaching and that the least activated ones needed much more support than we could offer and should be referred to more assistive services. The patients in the middle were the ones we focused on.


When we first began, our acceptance rate for post-discharge coaching and home visits was less than 50%. It’s now closer to 100%.


We realized that how we speak to patients and families is very important—you have 5-10 seconds to make a positive impression. Our community coaches were too sheepish at first, making it difficult for patients to trust them.

Consider why people are refusing. Some patients may just be embarrassed about people going into their home.

Organizational Background

Organization Name: Marin General Hospital

Location: Marin General Hospital, Bon Air Road, Kentfield, CA, United States

Organization Type: Hospital