Peninsula Circle of Care shares new and useful community services by mining the expertise of its individual team members.
Successful transitions depend on services offered in the community outside of the hospital. From city services to meal delivery, support groups, and faith-based services, our team was always on the lookout for new services for our patients. The challenge is that these services change all the time and there’s no central repository for all of them. So one person on our team might know about a great service, but others had never heard of it. The hospital has a Guide to Community Resources that is given to every patient upon admission, but some resources are outdated while others are not included.
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
We have a quarterly community resources share out. The entire transitions team is invited and we also invite hospital case managers, social workers, our home health agencies, and community organizations. People bring new services that they’ve learned about or share existing services that they have found very helpful. Our team also brings up challenges that their patients are facing and people can suggest services that they might find helpful. At the end of the meeting, we compile all the services mentioned and send them back out to everyone as a recap.
These sessions have really helped our whole team stay up to date on what’s out there. We’ve been able to better meet the needs of our patients because we’re aware of so many more services. We are working with Mills Peninsula to update the Guide to Community Resources so that every patient has access to these services. Our next step is to work with other community services and start combining them into a central electronic source to be shared with the general community.