Marin General partnered with community organizations to help with their outpatient coaching.
We were a strong believer that a transitions program had to have an in-hospital component and an out–of–hospital component. You can improve your discharge instructions as much as you want, but if the patient goes home and loses them, or does not understand or utilize them, you’re out of luck. Post-discharge coaching, therefore, was a core part of our initiative. The challenge was that we only had one year of grant funded resources to support a coaching program.
Marin General is a non-profit hospital in Greenbrae, CA. It has 250 beds and serves a mainly affluent suburban/rural population with pockets of low-income Latinos, African-Americans, and state prison inmates. Their transitions program began in 2011 and is influenced by the Care Transitions Program and Project RED.
What We Tried
We went out to the organizations in our community who were already working with people in our high-risk population. These included home health agencies as well as groups focused on senior care and county agencies. We introduced them to the Coleman model and offered them a small stipend to attend coaching training and work with our patients.
It took a bit of selling, but five community organizations agreed to partner with us. The benefit, as they saw it, was free training that would help them support not only our patients but also their other clients.
We didn’t have enough coaching resources to see all the patients that we wanted to see, but it was a start. It allowed us to practice and perfect. It also helped build a case for making coaching a more integrated part of our program. Once our ACO (Accountable Care Organization) got up and running, they took on a lot of the coaching responsibility so that we can see more patients now.
Make sure you have a long term funding plan if you go this route. We lucked out because our ACO took over most of the coaching after the first year. If they hadn’t, we would not have had the funding to provide ongoing support for our community coaches.