St. Rose tailored Project Red’s patient assessment form to the needs of their program and their patient advocates.
When we broadened our scope to look at more patients, we used Project Red’s risk assessment form to interview and enroll patients. The form was very detailed and long, making it hard for our patient advocates to get through it without overwhelming the patient with questions. Our advocates also found that, as they were chatting with patients and developing a rapport with them, there were other non-medical factors that seemed relevant to share with the team but no place to record these factors on the form.
St. Rose is a non-profit hospital in Hayward, CA. It has 217 beds and serves a diverse, low-income population including Spanish, Hindi, and Tagalog speakers. Their transitions program began in 2012 and is influenced by Project RED.
What We Tried
We developed an in-house assessment with the help of our patient advocates—it changes over time depending on what the patient advocate thinks is necessary or helpful. The first thing we did is simplify the form—we changed full sentences into a few words as notes and removed less relevant questions. We also added questions around the patient’s living situation, access to transportation, and health goals—questions that we’ve found have a significant impact on a patient’s chance of readmission. Since our patient advocates are non-clinical, we also added a section for referrals where advocates can jot down whether the patient needed additional dietary, respiratory, or medication coaching.
The revised risk assessment form gives us a more complete picture of our patients. We complete it when a patient is first admitted and then it becomes the core of their Project RED care plan. Our patient advocates continually refer to it to inform their coaching, make sure the appropriate members of the medical team are visiting the patient, and connect patients with beneficial support services post-discharge.
Since the patient advocates were very involved in the design, they’ve pretty much memorized it and don’t end up staring at a form while speaking to the patients. This lets advocates talk to patients naturally, instead of firing questions at them from behind a clipboard, and makes it easier to develop that strong relationship that is so important to their work. Once they leave the room they’ll fill in all the fields of the form and share it with the patient’s care team.
We didn’t make all of these changes at one time and we don’t consider the form done. We continually revise our form based on what the patient advocates want and need.