County of Marin Health and Human Services

Project Independence: Marin County's Care Transition Program

Care transitions take place when a person moves from one health care provider or health care setting to another.  Problems, such as missed doctor appointments, medication errors, and rehospitalization, often occur during these transitions because information is not communicated effectively.

Project Independence supports patients to transition safely from the hospital or skilled nursing facility, get their health care needs met during this vulnerable time, and stay independent at home.

Our highly-trained team of public health nurses, volunteers, nursing students, and support staff offer a variety of care transition services that are:

  • FREE!
  • Home and community-based
  • Individualized
  • Flexible

Who is Eligible

Marin residents 18 years and older who are isolated, lack social support, or are finding it difficult to manage their discharge plan and health needs on their own.

Results

Through Project Independence, participants are able to better manage their health conditions, connect to community resources, and sustain independent living at home. Since 2001, Project Independence has served over 1,000 Marin residents. Ninety-three percent of participants were restored to independence and/or linked to community resources.  Only 6% of Project Independence participants returned to the hospital within 30 days, compared to the national rate of 23% and the state rate of 19.6%.

Program Goals

  • Promote independence and autonomy of participants
  • Strengthen communication between providers, patients and family caregivers during care transitions
  • Reduce unnecessary hospitalization and nursing home stays
  • Improve coordination of acute, primary, and long-term health care services

Services We Offer

  • Visit participants at health care facilities and/or home and provide follow up phone calls for 4-6 weeks
  • Work with participants to create a transition plan for recovery based on their goals, priorities, and resources.
  • Help participants gain the skills and confidence needed to manage their own health care
  • Assist participants to follow their discharge plan   
  • Prepare participants for follow up appointments with doctors
  • Review the warning signs and what to do if a participant’s health gets worse
  • Help participants better understand their medications
  • Provide social support, transportation, and home safety checks
  • Facilitate access to health care and community resources such as home care, home-delivered meals, public assistance and transit programs

What is the cost?

There is no fee for this service.  Funding for this program is made available by the Marin County Department of Health and Human Services.