In addition to risk assessments and referrals, Peninsula Circle of Care lets patients who realize they need help sign up themselves.
We wanted to focus our efforts on the highest risk patients and we developed a risk assessment tool and referral program to find them. At the same time, we recognized that we wouldn’t be able to identify everyone who was at risk for being readmitted. Sometimes patients and their caregivers don’t realize until they get home that they need more help. We wanted to be able to help them, too, regardless of whether they were officially “high risk.”
Mills Peninsula is a non-profit hospital in Burlingame, CA that has partnered with the Palo Alto Medical Foundation and Peninsula Family Services to develop the Peninsula Circle of Care program. The hospital has 241 beds and serves a primarily elderly population (average age of 81) living alone with 90% on Medicare. Peninsula Circle of Care, their transitions program, began in 2012 and is influenced by the Care Transitions Program and a community based model.
What We Tried
From the beginning, we included a brochure for our program in patients’ admission and discharge packets. In it, we described our offerings and said that we would reach out to them if they were eligible. Later, we revised our brochure to say, “To find out if you are eligible, please call us.” Now patients or family members who need help at home can call us and enroll themselves into this program.
Self enrollment has been surprisingly successful. Patients need time to understand what their lives will be like after leaving the hospital. The brochure also lends credibility to the program, and the fact that it’s included with the hospital materials tells them we’re not a third party company trying to sell them something. Patients who self-enroll are also more motivated to work with us because they realized they needed help and took the initiative to reach out.
There might be concern that opening up your program to anyone will overwhelm your staff, but we haven’t noticed that problem. Only people who have really needed our assistance have reached out to us.