E-Drive: Discharge Navigator

Background & Challenge

At Zuckerberg San Francisco General Hospital (ZSFG), the emergency department often feels like an island—cut off from outpatient care, social services, and community support. Many patients arrive with needs beyond immediate treatment, but with no clear way to access the services that already exist in the community. As a result, they return to the ER again and again, straining resources intended for true emergencies.

Led by Dr. Peabody of the Acute Care Innovation Center, SOM Tech partnered with clinicians across specialties to design the Discharge Navigator. The goal: reduce low-acuity ED visits and provide care teams with a consistent workflow to connect patients with social support at discharge.

Seeing the Whole Picture

Our cross-disciplinary team applied design thinking to understand the people, systems, and programs shaping ZSFG. Through observations, stakeholder interviews, and participatory workshops, we mapped the safety-net ecosystem and identified constraints faced by patients, clinicians, nurses, and social workers.

Co-created personas and scenarios helped surface insights that shifted the tool’s focus: from patient-facing to provider-facing, from purely informational to decision-support, and from complex to simple. At its core was one actionable question guiding every interaction: “What do you need?”

Identifying People’s Needs

We started by uncovering the most pressing challenges clinicians face in connecting patients to community resources. Through observation, interviews, and social worker input, three recurring needs emerged—homelessness, substance use, and mental illness.

These insights directly informed the design of a digital prototype: a decision-tree tool guiding clinicians and residents to the right resources. It also generated clear, multilingual, and actionable patient handouts, ensuring patients left the ED with practical next steps.

Testing in Real Practice

Led by Dr. Stark, the prototype—built on open-source Drupal and managed by residents—was piloted in the ED for ten weeks. Residents used the tool in real patient encounters, refining workflows, evaluating usability, and ensuring it integrated smoothly into daily practice.

Surveys from the pilot confirmed the impact: clinicians reported increased knowledge and confidence in connecting patients to community resources, demonstrating how a simple, well-designed tool could make discharge more effective and reliable.