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Highland Hospital, a safety net hospital, worked with local organizations and volunteers to offer patients social services beyond medical care.
We are a safety net hospital and we use the Coleman Model, but we are flexible about it. Flexibility is important when patients have a lot of social needs. What if the patient doesn’t have an ID, or insurance, or a doctor, or a home? You’re starting from a very different place with these patients. Also, many of our patients have not built trust with a medical provider, so you have to build that if you want to be effective. That may take a little longer, but it’s worth it.
Highland Hospital is a non-profit teaching hospital in Oakland, CA. It is a safety net setting hospital with 236 beds that serves a diverse population including low-income, uninsured, and vulnerable populations. Their transitions program began in 2012 and is influenced by Project RED and the Transitional Care Model.
We used the same principles as the Coleman Model, focusing on coaching, but we started with the patients. We called them and visited them to really understand what they needed. A lot of our patients don’t drive and can’t take public transit, so we figured out how to sign them up for paratransit or printed out bus schedules and maps for them. Some had pest infestations at home. This distract them from taking care of themselves and often exacerbated conditions, so we reached out to the Department of Public Health to have them work with landlords to solve those problems. For patients without homes, we found ways for them to recover in shelters or hotels. We really just started with the patients needs and built our program up from there.
Sorting out what we can and can’t help patients with was a tough one for us. We’ve found social services that can help with food delivery or ride services, but we’re not going to be able to help someone find a home. We also work with volunteers whose role it is to stay on top of social services, connect patients with relevant ones, and then follow up with them to make sure they have what they need. One of the tools they’ve found very helpful is One Degree (https://www.1deg.org/), a Bay Area directory for social services.
Our program has been successful due in part to the fact that we go beyond the follow up phone call and home visit. We’ve really tailored it to the unique problems that our patient population faces. Going out of our way to help patients with everyday problems (not just the medical ones) really helps us gain credibility with our patients as well. When they’re in the hospital we tell them all these things that they need to do and change, but before we didn’t give them the tools to make any of those changes. It’s no wonder they weren’t receptive to our recommendations. Offering them something as simple as a bus schedule or a free cell phone can really help create a connection with them.
There are a lot of services available in the community to help patients. Whether they’re offered from the government or local nonprofits or even just volunteers. It takes time to find them, but it’s well worth it.
It’s important for us to always follow up with the patients. We check to make sure they are able to take advantage of a service—and, if not, we dig into why.
Patient and Family Challenges: Social Challenges
Topics: Identifying causes of readmission, Patient engagement, Using resources effectively
Organization Name: Highland Hospital
Location: Highland Hospital, East 31st Street, Oakland, CA, United States
Organization Type: Hospital