Much of what separates Penn Medicine from our peer institutions is our faculty and staff’s approach to addressing today’s health challenges, whether it’s with new technologies, life-changing therapies, or far-simpler, lower-cost interventions. There’s a shared principle among these drivers of change: complex problems require out-of-the-box solutions, always backed by insight, a willingness to try, and a desire to serve.
These ingredients have helped us usher in myriad sustainable programs to improve the health of our surrounding communities in need.
The IMPaCT program (Individualized Management for Patient-Centered Targets) is a shining example both locally and nationally that rethought the use of community health workers (CHWs). Developed by Dr. Shreya Kangovi, an assistant professor of Medicine, IMPaCT is distinguished by its scalable model that identifies, trains, and retains the best CHWs for the job. These workers have helped over 7,000 patients in the Philadelphia region work to overcome social determinants of health, like financial insecurity and a lack of insurance, and navigate the system. It has also helped reduce hospitalizations by 65 percent. And the model is financially viable. For every dollar spent, two dollars are saved in our Health System. Kangovi’s team is teaching this same model to hospitals across the nation.
This type of start-up innovation operates in so many corners of Penn Medicine.
Two of our cancer screening initiatives smartly use navigators to identify, guide, and support vulnerable patients at high risk, including a colorectal program led by Dr. Michael Kochman, a professor of Medicine and Surgery, and Dr. Carmen Guerra, an associate professor of Medicine and vice chair for Diversity and Inclusion in the department, as well as a breast cancer program led by Dr. Ari Brooks, a professor of Clinical Surgery, and Guerra. Cost-effective interventions like this help spot cancers earlier and introduce patients to a wider network of care that could potentially help prevent or treat other diseases — which can bring down overall health care costs.
The programs have been a growing success, with over 2,000 underserved patients in Philadelphia now screened. Abnormal polyps have been found and removed in 40 percent of those screened for colorectal cancer, while several women, who may have otherwise not known, have been diagnosed with various stages of breast cancer and subsequently treated at Penn as a result.
For many patients, this is their first introduction into our Health System, and because of these programs, they are provided with a level of trust that only improves our relationship.
Many new mothers wind up back in the hospital due to preeclampsia, a disorder characterized by high blood pressure related to pregnancy, that can worsen in the postpartum period. Heart Safe Motherhood, an effort led by Drs. Sindhu Srinivas and Adi Hirshberg of the department of Obstetrics and Gynecology, aims to prevent readmissions and morbidity by helping women monitor their blood pressure at home and engage in a texting protocol where Penn clinicians can act on high blood pressures to keep them safe while they are home.
Strategies to monitor blood pressure after patients leave the hospital had previously proven ineffective. From dedicated clinics to text-based appointment reminders to flexible scheduling, nothing moved the needle in a significant way until the team introduced this at-home monitoring intervention using blood pressure cuffs and text messaging with an automated response, with staff only required to get involved when pressures are too high. The results have been dramatic. In a large clinical trial, the team was able to move from achieving clinical guidelines (two readings during the first seven-10 days post discharge) for no patients to hitting that mark over 80 percent of the time, while reducing seven-day readmissions by 80 percent.
Now, it’s the standard of care throughout Penn Medicine for women at high risk for the disease.
Unmet social needs and poor access to primary care has also significantly increased the number of “superutilizers” of services, including the emergency room. Studies have shown that these patients are among the five percent of the population that accounts for nearly 50 percent of total health care costs.
This group has become a priority for many health systems, including ours. A multidisciplinary team led by Dr. Anna Doubeni, an associate professor in Family Medicine and Community Health, leveraged Agent, a technology platform developed at Penn to help clinicians easily see what or who requires action, to identify patients becoming high utilizers of our emergency rooms. Through the Priority Access Program, these patients are provided a care coordinator, telephone hotline, and transportation services to primary care, mental health, specialty care, and dialysis visits. The multidisciplinary team tailors interventions specific to the needs of each patient. It has worked extremely well, reducing hospital admissions by 43 percent and readmissions by 50 percent, as well as ED visits by 30 percent.
All these efforts, and many more, started out as relatively small, low-cost programs before growing. That’s the philosophy of the Penn Medicine Center for Health Care Innovation, which helped jumpstart and guide these approaches. Get the idea right first with proven, measurable outcomes or end points, and then scale up. The dedication and passion from our providers and staff is another key factor. We’ve learned that it’s the passionate, mission-driven innovators within the Health System who are making the greatest impact.
This approach has served us well. Through our innovative programs, we’ve shown and will continue to show that it’s feasible to marry the desire to care for our community with financial viability to treat underserved and vulnerable patients in meaningful ways.