Right place, right care
Penn Medicine is building better systems that help patients build care around their lives instead of their lives around care—and ideally avoid a hospital stay unless it’s truly necessary.
The nausea coursed through her body, an unwelcome companion during her cancer fight. This time it was bad, worse than normal. She needed help. But, instead of heading to the emergency department, she picked up the phone. Her oncology team coordinated with specially trained and outfitted nurses ready to react within moments—and a nurse from this Penn Medicine Cavalry team was dispatched to her home with intravenous medicines. Two hours later, the last waves of nausea dissipated, and her appetite returned. The fight continued, and she never had to leave her house.
Scenarios like this one are increasingly common, as Penn Medicine is reimagining many aspects of health care so that patients can more easily get the right care at the right time and place. This often means helping them safely avoid a trip to the emergency department, or to get the advanced treatments they need outside of a hospital setting. The ultimate goal, especially for patients with chronic and serious diseases, is to make it easier for people to build health care around their lives rather than building their lives around care. And the effort goes hand in glove with preventing chronic illnesses in the first place across the communities that Penn Medicine serves.
It’s a mission growing both in urgency and possibility. The population is aging, and more people are dealing with chronic conditions. Meanwhile, many smaller hospitals are closing under financial pressures, further driving demand for those that remain, especially in their emergency departments. And demand for inpatient hospital beds is consistently high.
“The journey we’re now on is, how do we now move acute care outside of the hospital?” said Penn Medicine Vice President and Chief Transformation Officer Raina Merchant, MD, MSHP. “How do we totally change the paradigm?”
Home is where the patient is (or wants to be)
The paradigm shift is built on the bedrock of home care that has already long been part of the Penn Medicine portfolio. The capabilities of Penn Medicine at Home were both tested and supercharged by the pandemic. Remote care and telehealth became vital connectors that opened the door to moving more care into the home.
“At this point, it’s about taking all of the lessons learned from care that we’ve been delivering at home for years, and building on that, making it sustainable so that it becomes part of the way that we operate as a system,” Merchant said.
Nurses and doctors can remotely monitor a patient's vital signs and maintain constant contact via tablet computers given to patients. Other technological advances have made it safer to deliver a wider range of chemotherapies and other infusions at home. Homes around the region have been connected into virtual hospital floors, centering care around patients on their terms.
Penn Medicine at Home is rare among home health care organizations in that it provides a wide variety of services to patients while thoroughly integrated as part of one system of care with inpatient, outpatient, and virtual care, through a single electronic health record. Its offerings have included palliative care, hospice, infusion therapy, and physical therapy.
“Our team understands the unique challenges of providing care in the home, such as variable space, caregiver availability, and the importance of adapting care to each family’s situation and needs,” said Joan Doyle, RN, BSN, MBA, the CEO of Penn Medicine at Home.
Now, new initiatives are taking advantage of this infrastructure to better connect hospital care with home care—or even supplant it.
Some programs are designed to ease the transition from the hospital to home.
For example, the Thrive program offers low-income patients extra support after a hospital stay—with virtual teams knitting together a safety net to reduce readmissions.
The goal is a more supportive transition to lower the likelihood that patients will need to return to the hospital, while helping patients navigate socioeconomic barriers that often impact health, such as lack of time or technical know-how to advocate with insurance or a lack of transportation. A keystone to the program is wrap-around care including the discharging provider from the hospital, a virtual care manager, home care nurse, and a social worker. Begun as a research initiative through Penn’s School of Nursing, Thrive is currently available to eligible patients at all of Penn Medicine’s hospitals in Philadelphia.
For other patients, SNF at Home, or Skilled Nursing Facility at Home, offers a smooth transition following care in the hospital for some major operations or strokes. The program provides the care patients would otherwise get in a skilled nursing facility in their home, such as physical therapy, occupational therapy, and daily visits from nurses, all coupled with additional services like virtual case management and virtual monitoring. The program leads to better outcomes for patients who also get to bypass the wait for a bed to open up in a SNF.
Other programs are helping patients get hospital-level care at home.
“For many, many years there’s been the hospital and there’s been the clinic. And we are now in a third space in between,” said Anna Morgan, MD, MSHP, physician lead for population health initiatives for the Center for Health Care Transformation and Innovation at Penn Medicine. “The patients are at home, but they’re not getting what we would consider more traditional home-level care. Instead, they’re potentially getting hospital-level care in the home.”
In one such program launched in 2024 and studied for future expansion, Practical Alternatives to Hospitalization (PATH) patients with conditions including chronic obstructive pulmonary disease (COPD), heart failure, and infections could avoid being admitted to the hospital from an emergency department visit or be diverted from an inpatient stay, and instead receive virtual and in-person care at home under the supervision of a team of providers and nurses. The program initially ran from September 2024 through June 2025, with plans to later resume and scale up.
The PATH program enrolled 177 patients over 12 months and exceeded its benchmarks for patient outcomes. Now the focus has turned to looking at how to sustain PATH long-term as a companion program to the newest, most comprehensive piece of Penn Medicine’s remote care portfolio: Hospital at Home.
This summer, Penn Medicine received approval for a waiver from the Centers for Medicare and Medicaid Services (CMS) to provide hospital-level acute care under the operations of all seven of the health system’s hospitals. This CMS waiver means that many patients’ insurance plans will cover the cost of acute hospital-level care that Penn Medicine provides at home with at least two daily visits from nurses, among other required services. Plans are underway to initially roll out the Hospital at Home program for the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, and Lancaster General Hospital, in early 2026, with later expansion to the rest of the health system.
Urgency, not emergency
The broader goal of these various initiatives is to make care seamless for patients, with easy options throughout their health care journey—including pressing issues that require attention at an unexpected or odd time.
“It’s urgent care at home,” said Danielle Flynn, MSN, RN, describing the Cavalry program, which she co-developed and now oversees as part of her role as home health system director in Penn Medicine at Home. This specially trained team of seven nurses with a background in emergency care is equipped to manage patients with heart failure, COPD, and cancer. The program covers Montgomery, Delaware, Bucks, and Philadelphia counties from 9 a.m. to 9:30 p.m. Monday through Friday.
“The biggest population we have is oncology. They need IV fluids. They need medicine for nausea. They need support in the home for whatever symptoms they have,” said Flynn.
The Calvary team is activated after a patient calls their provider about their symptoms; a clinic team assesses the call, and if the symptoms meet certain criteria, then a nurse heads out to answer the call. The average time from Cavalry activation to doorstep is one hour and 36 minutes.
When the nurses arrive, they assess the patient and call the doctor for verbal orders. They can draw labs, place an IV, or access a port to provide medication or fluids. This gives an immunocompromised patient a chance to receive care without exposure to the hospital.
“It’s an absolute win for them,” Flynn said, because these patients additionally can avoid the drive and the wait in the emergency department. “It’s also a win for them to be at home with their family.”The concept of “urgent care for cancer patients” has an on-site clinic component as well. At the Oncology Evaluation Center at HUP, patients can receive transfusions, infusions, and therapies. The center recently expanded to offer 24/7 service in a new, dedicated space in the hospital.
HUP also houses the Symptom Management Service, which focuses on treating non-cancer patients. Patients in ongoing treatment for conditions such as sickle cell disease and heart failure are referred by their primary team for symptoms like dehydration, nausea, or vomiting, for which they might need a diuretic or an IV steroid.
“They’re going to come to us, we’re going to get them in a chair pretty quickly. We’re going to give them whatever interventions they need and we’re going to get them home. That’s the goal,” said Caitlin O’Neill, DNP, RN, clinical director of the HUP-based infusion suite.
Each treatment also provides information that will improve care for future patients. O’Neill said they are constantly refining the criteria for which patients will gain the most from treatment so those groups can be targeted with information about the service.
Steering patients toward better paths
Not everyone is eligible for the specialized programs that help certain patients avoid a trip to the emergency department or a hospital admission. But Penn Medicine has several other ways to help more patients find more convenient avenues for the right care in the right place. It starts with a rewiring of the widespread view of the emergency department as a destination of first resort.
Penn Medicine Lancaster General Hospital earned some of the system’s earliest successes in that rewiring. In 2017, its emergency department was seeing about 110,000 visits a year, double its capacity, “leading to long waits, high costs, and misallocation of resources,” said the hospital’s executive medical director for primary care and population health, John Wood, MD, MBA, FAAFP.
Wood said the hospital leveraged its primary care and urgent care network to educate patients about which conditions merited an emergency department visit, versus a trip to one of Lancaster General Health’s growing number of urgent care facilities in the area.
People also learned to trust telehealth solutions to a greater degree during the COVID-19 pandemic. This offered patients yet another convenient option for care that, for many conditions and symptoms, meant they didn’t need to visit the emergency department or in-person urgent care center.
“The goal is to get the patient to the right place the first time,” said Jaclyn Owens, PA-C, the clinical director of LG Urgent Care on-demand and virtual platforms.
Penn Medicine saw similar rapid growth in usage of the Penn Medicine OnDemand virtual urgent care service during and after the COVID pandemic. The service is available around the clock to patients across the wider region Penn Medicine serves in Pennsylvania, New Jersey, and Delaware. An analysis of its use by Penn Medicine employees showed that it reduced the cost of care per visit, compared to an in-person primary care, emergency department, or urgent care visit.
Helping patients more easily get the right care in the right place is a priority for transforming care across Penn Medicine—whether that care is urgent, acute, chronic, or preventative. An ongoing multi-year initiative called Project Ascend that aims to streamline access to appointments with improved customer service and more self-service options, is another major effort in that push to simplify the patient experience while improving care.
Problem solvers
All of these programs can be viewed as answers to specific problems that patients face while seeking care. But these problems are nested inside a much larger challenge: How can medical systems make it easier for people to live and manage their health in ways that fit health care more easily into their lives, instead of shaping their lives around care?
Mark Angelo, MD, MHA, joined Penn Medicine in the newly created role of chief medical officer for population health last year, in part to take on this question, focusing on the needs of specific groups of patients.
Angelo found that Penn is a place full of people who don’t shy away from taking on large and complex problems.
“We look at it from 10 different angles, and we all get together, and we all kind of throw our hat in the ring to think about how we might look at this differently, how I might take some responsibility for it, how you might want to think of things from my perspective.”
For Angelo, the problem of how to get patients the right care at the right place is even farther upstream than clinical visits and programs. It’s about how to keep people healthier in the first place, so that they have fewer needs for hospitals and emergency departments. This work looks at the factors that feed into different outcomes for different populations. For example, is food insecurity a reason why some patients can’t afford even relatively low-cost treatments—like inhalers for COPD—and land back in the hospital at higher rates?
“It is really a privilege to join the Penn Medicine team at such a critical time. We are working to solve the problem of how we manage the health of our populations to get the best quality and cost outcomes,” Angelo said.
It’s a different way of looking at medical care with an emphasis on supporting patients’ overall health, before small problems become big problems. But when problems do happen, they should be easy to handle.
To that end, Angelo is helming a comprehensive reimagining of the flow of care at Penn Medicine called Project RightCare, together with Population Health Medical Director Corinne Rhodes, MD, MPH. “We really think that we can bend the curve of the patient’s health as well as the costs that are associated with that health,” said Rhodes. “Both of those things go hand in hand.”
Under the framework of Project RightCare, the numerous dots in the constellation of programs that simplify care for patients are becoming better connected.
“I think that marks what’s really been exciting as we’ve done a lot of this Project RightCare work,” said Angelo, “to see how many programs we have at Penn, how much innovation there is happening across our system.”