‘You got me for three months’: A community health worker helps patients navigate life after a hospital stay
Penn Medicine community health worker Georgieanna “Gee” Pierre-Paul helps patients navigate appointments, medications, transportation and other challenges after discharge—building the trust that can make a care plan work at home.
For Georgieanna Pierre-Paul—who wants everyone to call her Gee—the most important part of her job may be a comfortable pair of shoes.
Gee spends most days on her feet, moving between the Penn Center for Community Health Workers, clinical settings and emergency departments such as the one at Penn Presbyterian Medical Center, and the homes of patients who have been discharged from a hospital.
For about three months, she partners with patients as they transition from the hospital back into their daily lives, helping them identify their goals, navigate barriers such as food insecurity, transportation, and isolation, and connect with care and resources such as social services. Patients may be referred by their care team or identified based on where they receive care, their ZIP code, and whether they have public insurance or are uninsured. Those eligible for in-person support generally live in West, North, or South Philadelphia and are either admitted to a Philadelphia-area Penn Medicine hospital or receive care at a participating primary care practice. Patients referred by their care team who do not meet the criteria for in-person support may receive support by phone.
Her role reflects a growing recognition in health care: A prescription, referral, or discharge plan works only if it fits a patient’s life and accounts for circumstances affecting health that may not emerge during a clinical encounter.
Taking care everywhere
Walking through Penn Presbyterian Medical Center one day, Gee heard a familiar voice from a patient transport van: a former patient arriving for a follow-up visit. Gee quickened her pace and checked in. How had the patient been feeling? Had she made her follow-up visits? Did she have what she needed at home?
That continuing connection is at the center of Gee’s work as a community health worker at Penn Medicine. Community health workers are trusted members of the communities they serve who help patients identify goals, overcome practical barriers, and connect with care and resources; they are not clinicians.
The Penn Center for Community Health Workers developed IMPaCT, an evidence-based program that improves patients’ health and well-being, more than a decade ago. Since its creation, IMPaCT has supported more than 28,000 Penn Medicine patients. Research shows that the program enhances patient satisfaction, improves mental health and chronic disease management, and reduces health care costs by shortening hospital stays. More than 60 organizations across the country have implemented the Penn-developed model.
Community health workers bring lived experience, empathy, trust, and firsthand knowledge of the neighborhoods they serve to the care team, said Jovan Bennett, senior director at the Penn Center for Community Health Workers. Their work continues after patients return home, where they can better understand the realities affecting health and help patients navigate them. “That continuity builds trust, supports behavior change, and bridges the gap between clinical care and everyday life,” Bennett said.
Community health workers often work across hospital, clinic, and community settings. That position helps them support a patient’s care while helping other members of the care team understand the life circumstances affecting the patient’s health.
Gee describes the role more simply: helping someone “piece their life back together.” The practical work depends on trust and on understanding what may keep a patient from moving forward.
That trust was clear during a visit with Wanda Boyd, who was recovering at her West Philadelphia home after being struck by a car.
Gee turned Boyd’s concerns, including transportation, appointments, and the need for a mobility cane, into next steps. “I didn’t know I could get one,” Boyd said of the cane.
“You got me for three months, so we can work on some things,” Gee replied.
Gee also asked what Boyd hoped to return to as she recovered. Boyd named “my children and my grandchildren, fiancé, and Jesus,” and said she wanted to get back to church.
“I want to try to help you get back there,” Gee said, adding that goal to the recovery plan.
A role shaped by lived experience
Gee’s path to this work began before she even knew the job existed. She cared for her grandmother after a stroke and became the neighbor people called for rides and resources. “I’m a natural helper,” Gee said. “I’m always trying to stay people-centered.”
Gee’s daughter, now 17, was born extremely premature and spent more than a year in the hospital. When she came home, Gee coordinated nursing care and learned to translate clinical recommendations into family life.
Nonprofit organizations helped with essentials such as diapers and a crib. Later, while volunteering with the Maternity Care Coalition, a Philadelphia nonprofit that supports pregnant people and families with young children, an advocate urged Gee to apply for a community health worker position. The years she had spent outside the traditional workforce caring for her family became part of what prepared her for the role. She entered the field in 2014.
On a typical day, Gee reviews records, contacts clinicians, meets patients at the bedside, and turns long lists of needs into practical roadmaps. She typically supports 16 to 18 active patients at a time and contacts them weekly to build rapport, stay on top of their needs, and help make sure they do not fall through the cracks or go without support. Beyond that required clinical groundwork, she gives patients the time and attention to talk through the needs and challenges that standard questions may not reveal.
Boyd’s need for a mobility cane had not surfaced through routine clinical questions. It became clear through a broader conversation about her independence, family, and daily routines.
“It’s that trust piece,” Gee said. Patients help her understand “where they’ve come from, where they are,” and what might make life more manageable.
Closing as many loops as she can
Even small barriers can slow or stop care.
A patient without a working phone may miss calls from a home-care agency, follow-up appointments, therapy, or nursing support. Another may struggle to access patient-portal messages or multifactor authentication in a world largely powered by digital communication.
Gee once kept a referral from being canceled when a patient could not be reached directly. “I’m calling, like, ‘Hey, don’t cancel. This is the patient’s aunt. She lived next door. Call her," Gee said. “It seems like a small fix, but that can be detrimental.”
Community health workers can often see the difference between a patient who is unwilling to engage and one who is facing barriers that make engagement difficult. That understanding allows them to help the care team respond to what is actually happening in the patient’s life.
She is direct about what the program can do, emphasizes that participation is voluntary, and reminds patients, “You’re the expert in your own life.” Sometimes the work means repairing trust after a difficult hospital experience; often it means showing up consistently enough that the offer of help feels real.
Back in the hallway at Penn Presbyterian Medical Center, Gee’s former patient continued toward her appointment. Gee had no form to complete. She simply checked in, listened, and reminded the patient how to reach her.
The moment captured what can be lost in the word “discharge.” Leaving the hospital is not the end of care; it begins with a new set of decisions and obstacles. Gee helps patients with a plan—and with someone who remembers their story.
Then she glanced down at her patient files and headed to the next visit, ready to start again.