Letting patients choose their own transition plan

2 minute read

Letting patients choose their own transition plan

< 1 minute read

VA Palo Alto asks patients how they can help them rather than telling them about the components of their transitions program.

The Issue

Our patients are all vets—they can be self-reliant, stubborn, and stoic, to the point of waiting too long to ask for help and then getting readmitted to the hospital. Sometimes they would say “no” once we started talking without even knowing what they were saying “no” to. We can’t create care plans for people who won’t accept our help. We had one patient who said he didn’t want a follow up appointment, but we insisted and scheduled one for him anyway. He cancelled his appointment before he even left the hospital.


VA Palo Alto is a government-affiliated teaching hospital in Palo Alto, CA. It has 885 beds and serves primarily English-speaking US veterans with comorbidities requiring both acute and chronic care. Their transitions program began in 2012 and is influenced by Project RED.

What We Tried

We try to let patients create their own care plan. With transitions, the important thing is to develop a strong relationship with the patient so that they feel comfortable asking for help when they’re ready for it. So instead of saying “We’re going to come to your home,” we say “There are a lot of different ways we can work together. We can go to your home to check up on you, or just give you a call, or I can just give you this discharge packet with helpful information on your medication. What would work for you?”


Surprisingly, not forcing our program on patients has really helped us connect with them better. Sometimes we just end up giving them the After Hospital Care Plan and nothing else, but they trust us for letting them make the decision. Then if they have questions when they get home they feel more comfortable calling us since it’s their choice and not something we told them to do. Not having a follow up appointment or phone call within 14 days is a metric hit, but it’s a patient win if it lets you create a stronger relationship with patients. They’ll be more committed to their care plan if they are a part of creating it.

Patient and Family Challenges: Not Receptive to Our Help

Topics: Patient engagement

Organizational Background

Organization Name: VA Palo Alto

Location: 3801 Miranda Avenue, Palo Alto, CA, United States

Organization Type: Hospital