Highland Hospital looked to their local community to find a transitions team member who could relate and connect with patients during home visits.
We’re a safety net hospital and many of our patients come from backgrounds different from that of our professional staff. We wanted to find ways to build trust with patients in spite of these differences, and truly connect with our patients in a more personal way.
We also had nurses and social workers doing home visits, and they were honestly overqualified for this. We don’t need licensed professionals to help patients sign up for meal delivery or transit support. Still, those tasks are very important, so we wanted to find someone who was more affordable and could connect with patients in their homes.
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.
What We Tried
We found a program offered by the Department of Public Health that trains young men in the community to be EMS workers. They’re not college graduates, but they learn about managing diabetes, asthma, and hypertension and are trained in med rec. We hired one of these graduates to join our program.
He gives every care transitions patient a call after discharge to get a sense for how they’re doing. If they don’t sound good on the phone, he’ll refer them to a nurse for a more in-depth phone call or home visit. If they seem like they’re doing ok but could benefit from some more coaching, he’ll go out for a home visit. Once there, he’ll conduct a brief psychosocial assessment to identify common obstacles to self-care like whether they have access to food and health insurance, whether they can read their prescription bottles, and whether they have substance abuse issues. He also helps with medication reconciliation and can connect patients with relevant social services.
After the home visit, he shares his assessment of the patient condition with our care transitions nurses. Together they decide whether the patient is in a good spot or needs further coaching or home visits from nurses or even a pharmacist.
Creating this new role has really changed the way we interact with patients. Since the role is dedicated to calls and home visits, he’s able to see more patients sooner than we were able to before. He also frees up our nurses to focus only on the patients that really need a nurse’s expertise.
Being from the community, he’s also able to connect with many of our patients better. He’s very passionate about working with our patients and understands their living situations really well. We’ve had patients who have left our program call him back a few months later to ask for more support.
It’s been inspiring to see how passionate our community outreach worker is about working with and for his community. It has really reinvigorated our team.
Since the new team member is more affordable than a nurse or social worker, we’re able to work with more patients without increasing our costs dramatically.
You need to find the right person for this role. We wanted someone from the community who understood the needs of our more disadvantaged patients, but we also needed someone who could represent our hospital in a professional way. We’ve had to provide a lot of support for this new role, but he has also enriched our program significantly.