CareInSync and Marin General Hospital Announce Nation's First Mobile Care Transitions Network

GREENBRAE, CA — CareInSync and Marin General Hospital announce the formation of the Nation’s first Mobile Care Transitions Network™ in Marin County, California, connecting physicians, nurses, caseworkers, and home care managers across seven health care organizations. Powered by Carebook™, the network brings together patient-centered teams across disparate organizations in real-time, enabling safe and timely care transitions for patients.

The Marin County Mobile Care Transitions Network™ is an unprecedented mobile technology-enabled collaboration anchored by Marin General Hospital, supported by the Gordon and Betty Moore Foundation, and including Sutter Care At Home, Marin County Health and Human Services, Marin Community Clinic, Meritage ACO, West Marin Social Services, and Jewish Family Services. Health care professionals at these independent organizations are brought together as active, engaged members of the patient care team by CareInSync’s Carebook mobile platform. As patients transition out of Marin General Hospital, Carebook automatically risk-stratifies patients and applies risk-specific evidence-based interventions to ensure efficient focusing of the right resources at the right time, resulting in a better outcome and an improved patient experience.

Select interventions from Project RED® (Boston University’s Re-Engineered Discharge), Project BOOST® (Society of Hospital Medicine’s Better Outcomes for Older Adults through Safe Transitions), the Care Transitions Intervention® and the Marin General Hospital’s own best practices have been brought together to implement COAST@Marin™ (Collaborative for Older Adult Safe Transitions at Marin), powered by Carebook. By coupling evidence-based interventions with a real-time multi-disciplinary team communication platform, Carebook is addressing the single most important barrier to improving health care quality and cost: the dangerous communication gaps that occur during health care transitions, particularly when multiple organizations are involved.

“Marin General Hospital has been looking for a way to improve communications amongst members of a care team, but also to make sure that all elements of an evidence-based discharge get completed in a timely fashion. Carebook has provided an elegant solution to this,” says Susan Cumming, MD, SFHM, Medical Director at Marin General Hospital, visionary and architect of the COAST@Marin program. “Carebook has been adopted by care providers because it has broken down barriers to communication, and has served to flatten the communication hierarchy. Streamlining these communications contributes to enhanced patient safety.” Sharon Reid, an RN Case Manager at Marin General Hospital, adds “I love being able to instantly communicate a patient’s discharge plan to the entire team at once. It helps all of us on the team to coordinate our workload, and to respond immediately to urgent issues that can make a big difference.” Kareen Ferrer, RN, a bedside nurse at Marin General Hospital says, “Carebook has had a huge impact on nursing workflow. As nurses, we get an immediate response when we send a message to the MD. We don’t have to page them and wait for a callback.”

Post-discharge community care providers are also excited about how the tool is helping them deliver safer and more timely care to their patients. Danielle Hiser, a post-discharge Care Transition Coach from Marin County DHHS, adds “An alert appeared in Carebook, reminding me to visit a high-risk patient at home for transition coaching the day after discharge. I was able to make a big difference by teaching this patient how to manage their own care as they transitioned from the hospital stay to home. Before Carebook, this opportunity to influence a positive outcome could have been missed.”