The benefits of a transitions program with multiple points of view

3 minute read

The benefits of a transitions program with multiple points of view

< 1 minute read

VA Palo Alto created a truly multidisciplinary team by putting people in charge of roles outside their areas of expertise

The Issue

We brought together a multidisciplinary team to implement the 11 elements of Project RED. It’s a huge program, so we wanted to create separate teams with a lead for each element. The danger of splitting into sub-teams is that everyone might just focus on their own area of expertise and we wouldn’t get the big picture view that a multidisciplinary team is supposed to provide.


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 assigned leads to elements that weren’t in their area of expertise so that they could bring a fresh set of eyes to the topic. For example a social worker was in charge of the element around organizing post-discharge services even though that’s the role of case managers and home health nurses. We also asked the chief nurse of ambulatory care to lead the post-discharge calls element because her department is the one that gets called when the post-discharge calls aren’t effective.


Both of those leads were confused at first, wondering why I was putting them in charge of something they knew very little about. They both did remarkable things with their elements though. Since they had an outside perspective, they were able to focus on the process rather than the content. If our case managers had been assigned to the post-discharge services element they would have focused on which services were available and how to secure more of them. The social worker was able to step back and notice how broken the process of organizing post-discharge services was in the first place.

The same thing happened for the post-discharge calls element. The chief nurse for ambulatory care made sure the team didn’t just look at the calls themselves, but how they fit into the overall care pathway from admission to hospital to discharge and then self-care. Ultimately she made post-discharge calls into the feedback loop for the entire project. Anything the nurses learned on those calls would be fed back to the teams to improve care in the hospital.


It really helped us to have a few people in mind to lead the teams and then approach them to gauge their interest. If we had an open call for volunteers we might have ended up with people who are generally overcommitted. If we assigned people to the teams we might have ended up with people who weren’t really committed to the project.

Organizational Background

Organization Name: VA Palo Alto

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

Organization Type: Hospital