Written by: Center for Care Innovations

Idea: Test a “remote house call” between newly-discharged patients and their care teams, using a smart phone that is lent to the patient (with training) prior to discharge.

Target: Established PHC patients hospitalized for a severe condition and at risk for readmission; project patients also must be able to use a digital device or have a caregiver who is.

Project Highlights: The Innovation Team’s solution to use a remote house call is intended to work like “a real office visit,” with the participation of the patient’s full care team and integrated into the routine workflow. Through experimentation, the Team developed these simple criteria: the patient has previously established care at PHC, is at risk for readmission for any reason, and is capable of using technology or has a caregiver who is. Based on a successful pilot phase, PHC plans to expand its use to other hospitals that admit PHC patients and in shelters and skilled nursing facilities where its patients reside.

Evidence of Cultural Change from the Innovation Process

• The organization has incorporated a culture of innovation into its strategic plan.

• Through CCI’s Innovation Center for the Safety Net initiative, Petaluma has developed a formal innovation team that will be tasked with bringing people together to develop innovative solutions to difficult problems.

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