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March 26, 2013 // By Kim Menard // Comments

Community Health Workers Deployed to Support Vulnerable Penn Medicine Patients

Community // Patient Care Share this article

Last week, a fleet of community health workers fanned out to help patients in need of some extra support, as part of an ambitious new Penn Medicine program that brings relatable neighbors and peers on board to help vulnerable Penn Medicine patients navigate the medical system and address underlying causes of illness.

Poor health is only one reason why vulnerable patients bounce back to the hospital shortly after being discharged, or have a hard time managing chronic conditions, and the IMPaCT program - Individualized Management for Patient-Centered Targets - hopes to change that. IMPaCT Partners are specially-trained community health workers who share life experiences with the patients they serve. These "natural helpers," who have shared [language, ethnic and geographical] backgrounds as many of the patients they will serve, were selected for characteristics including good listening skills, non-judgmental nature, reliability, availability and knowledge of their communities.

The community health workers provide social support, navigation and advocacy to socioeconomically vulnerable patients who are low income, insured by Medicare and/or Medicaid, or are uninsured. There are two programs - one for hospitalized inpatients and one for primary care outpatients.

A selected group of patients who may be low-income, insured or underinsured cared for by the General Medicine services of the Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC) meet with an IMPaCT Partner on the first day of hospitalization to set short term goals and identify pathways to solve some of their clinical and socioeconomic hurdles. During their hospitalization, the IMPaCT Partner rounds with the doctors, nurses and pharmacists on the unit, advocating for patients, sometimes by suggesting a more affordable generic medication or home visits from a physical therapist if transportation is a challenge. On the day of discharge, the Partner is there to make sure discharge instructions are well understood and achievable. Over the next two or three weeks, the Partner continues to work with the discharged patient outside the hospital to help them get connected to resources in their community. The IMPaCT Partner helps the patient select and go to an appointment with a primary care doctor.

On the primary care side, two clinics at 3701 Market Street are pairing vulnerable patients dealing with chronic conditions with an IMPaCT Primary Care Partner.  At the outset, the patient and care provider collaborate to determine a specific health goal and realistic expectations. Over a 6 month time frame, the patient works with their IMPaCT partner to break down the goals into achievable steps. For some, it may be addressing food insecurity or non-medical related issues such as difficulties affording heat, or housing issues. For others, it may be working towards a particular health goal, such as consistently getting and taking medications, or addressing an addiction. The support framework gives the patient a better chance to follow-through on some of the doctor's prescribed goals, with the help of an IMPaCT Partner to guide them through it.

Penn's IMPaCT Program is done in partnership with three community-based organizations (Spectrum Health Services in West Philadelphia, Enterprise Center CDC and the Health Federation of Philadelphia). In addition to helping patients reach their goals and maintain health, the program is also conducting continued research and developing a turn-key training model for Community Health Worker-supported programs, as part of the Penn Center for Community Health Workers.  Given the interaction with home care nurses who often see some of the same patients, the program is housed within Penn Home Care and Hospice.

Video credit: For Penn Medicine by David Cribb, Debbie Foster and Aaron Johnson.

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