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Case Study: Coordinate, Coach, Transition

How to improve care transitions for socially vulnerable patients? Secure the safety net.

PROBLEM: 

An alarming rate of hospitalized patients with complex social needs are rehospitalized or return to the emergency department within 30 days.

Solution: Hospitalized patients with significant social needs are at risk for poor health outcomes following a hospital discharge. To meet their needs, J. Margo Brooks Carthon, PHD RN FAAN, Associate Professor of Nursing, spearheaded a work group to develop an intervention that would improve their transition from hospital to home. Using a Design Thinking framework, which drew on her experiences as a Penn Nurse Innovation Fellow, Dr. Brooks Carthon and the team learned through months of fieldwork that concerns over finances, housing instability, or a lack of transportation left many patients feeling as though they had to manage their recovery alone. In the hospital setting, the workgroup learned that there were notable variations in how patients with complex social needs were managed across units and that there was limited communication between inpatient and outpatient care providers.

These insights led to the development of THRIVE, a clinical pathway focused on supporting patients in their homes in the month following a hospitalization so that they are equipped and empowered for maximal recovery. THRIVE was built on three pillars: Coordinate, Coach, and Transition, with each pillar providing a powerful and transformational approach to care delivery for socially vulnerable patients.

Coordinate

Nurse Case Managers begin the process of identifying patients with high social needs during hospitalization. After a THRIVE patient is identified, a home care referral is made and on the day of discharge the floor nurse gives a verbal report by phone to the home care nurse to share important social and medical history. Prior to THRIVE there were no formal mechanisms for inpatient and home care nurses to verbally communicate. Hospitalized patients are then immediately able to meet their home care nurses using a secure patient-facing video conferencing system. This “virtual introduction” begins the important process of relationship building.

Coach

On the day after discharge, THRIVE enrollees receive a visit from a home health nurse. During ongoing visits, home care nurses serve as health coaches, providing patient education, reviewing medication orders, and supporting patients as they schedule primary care and specialist appointments.

Transition

THRIVE also expands the role of hospital-based attending physicians by making them available by phone to home care nurses for questions or additional orders until patients receive a follow up appointment with a primary care provider. This ensures that transitional needs that often emerge after discharge such as questions about medications or physical symptoms can be addressed in real time.

Penn Presbyterian Medical Center is currently conducting rapid cycle pilot testing of THRIVE and is targeting Medicaid patients living in Philadelphia with high disease burden. During evaluation, enrolled patients will be assessed for whether they experience fewer rehospitalizations or ED visits during their first 30 days post discharge.


Funding for development of THRIVE included a Penn Nurse Innovation Fellowship; the Leonard Davis Institute; Penn Medicine Center for Health Care Innovations. Analytic support from post- doctoral fellow funded by CHOPR T-32.