Peninsula Circle of Care tries to ensure that new team members are introduced to patients by someone they already know and trust.
Our program has three different points of contact—a liaison enrolls patients in the hospital, then a nurse and/or social worker will visit them at home for a month, and a wellness coach will continue working with them after that initial month if there are outstanding unmet needs. It can be confusing and uncomfortable for our patients to have new faces show up at their home. How do they know they can trust these people? Why are they being handed off from one person to another?
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 try to have warm handoffs whenever a new person is being introduced to the patient. So, in the case of the wellness program, the wellness coach would do a joint home visit with the nurse and/or social worker to introduce themselves and explain how they would continue the work that the nurse and/or social worker had done.
Logistically, it’s much harder for the nurses doing home visits to also meet the patients in the hospital. In that case, we make sure that the liaison tells the patient exactly who will be visiting them. “Once you go home, one of our nurses, Patricia, will be visiting you.” This way patients don’t feel like it’s a total stranger coming into their home.
We’ve had more success with patients accepting home visits and wellness coaching with these warm handoffs. It sets them at ease to know that everyone working with them is a part of the Peninsula Circle of Care and we’re all working together to help them get better.
When you can’t do a warm handoff, referencing people the patient knows is a good tactic. “Laura, your social worker, wanted me to reach out to you.” That way they can at least connect you to someone they’re comfortable with.
Another way we help put patients at ease when they’re meeting new people is to give everyone on the team a Peninsula Circle of Care badge. That way, even if patients don’t recognize a face or a name, the person still looks official.