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Community Health Workers Deployed to Support Vulnerable Penn Medicine Patients

Last week, a fleet of community healthworkers fanned out to help patients in need of some extra support, as part ofan ambitious new Penn Medicine program that brings relatable neighbors andpeers on board to help vulnerable Penn Medicine patients navigate the medicalsystem and address underlying causes of illness.

Poor health is onlyone reason why vulnerable patients bounce back to the hospital shortly afterbeing discharged, or have a hard time managing chronic conditions, and the IMPaCTprogram - Individualized Management for Patient-Centered Targets - hopes tochange that. IMPaCT Partners are specially-trained community health workers whoshare life experiences with the patients they serve. These "naturalhelpers," who have shared [language, ethnic and geographical] backgroundsas many of the patients they will serve, were selected for characteristicsincluding good listening skills, non-judgmental nature, reliability,availability and knowledge of their communities.

The community health workers provide socialsupport, navigation and advocacy to socioeconomically vulnerable patients whoare low income, insured by Medicare and/or Medicaid, or are uninsured. Thereare two programs - one for hospitalized inpatients and one for primary careoutpatients.

A selected group of patients who may below-income, insured or underinsured cared for by the General Medicine servicesof the Hospital of the University of Pennsylvania (HUP) and Penn PresbyterianMedical Center (PPMC) meet with an IMPaCT Partner on the first day ofhospitalization to set short term goals and identify pathways to solve some oftheir clinical and socioeconomic hurdles. During their hospitalization, theIMPaCT Partner rounds with the doctors, nurses and pharmacists on the unit,advocating for patients, sometimes by suggesting a more affordable genericmedication or home visits from a physical therapist if transportation is achallenge. On the day of discharge, the Partner is there to make sure dischargeinstructions are well understood and achievable. Over the next two or threeweeks, the Partner continues to work with the discharged patient outside thehospital to help them get connected to resources in their community. The IMPaCTPartner helps the patient select and go to an appointment with a primary caredoctor.

On the primary care side, two clinics at3701 Market Street are pairing vulnerable patients dealing with chronicconditions with an IMPaCT Primary Care Partner.  At the outset, thepatient and care provider collaborate to determine a specific health goal andrealistic expectations. Over a 6 month time frame, the patient works with theirIMPaCT partner to break down the goals into achievable steps. For some, it maybe addressing food insecurity or non-medical related issues such asdifficulties affording heat, or housing issues. For others, it may be workingtowards a particular health goal, such as consistently getting and taking medications,or addressing an addiction. The support framework gives the patient a betterchance to follow-through on some of the doctor's prescribed goals, with thehelp of an IMPaCT Partner to guide them through it.

Penn's IMPaCT Program is done in partnershipwith three community-based organizations (Spectrum Health Services in WestPhiladelphia, Enterprise Center CDC and the Health Federation of Philadelphia). In addition to helping patients reach their goals andmaintain health, the program is also conducting continued research anddeveloping a turn-key training model for Community Health Worker-supportedprograms, as part of the Penn Center for Community Health Workers.  Giventhe 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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