Philadelphia program sends caseworkers to disadvantaged neighborhoods to improve outcomes

Philadelphia skyline at night
A program that asks patients in disadvantaged neighborhoods what they need to improve their health yields improved outcomes and saves money. (Image: Getty/Ultima_Gaina)

An innovative program run by the University of Pennsylvania Health System uses a patient-centric focus to extend care beyond hospital facilities and into local communities.

A new case study (PDF) describes the Individualized Management for Patient-Centered Targets (IMPaCT) care model developed by Penn’s Center for Community Health Workers, which has demonstrated improved outcomes and a two-to-one return on investment. The key to the program’s success lies in sending its community health workers into disadvantaged neighborhoods throughout Philadelphia and asking patients what kind of support they need to improve their health.

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That approach involves a bit of a leap of faith for physicians whose typical focus lies within the four walls of the hospital, Shreya Kangovi, M.D., who developed and launched the model, told the CEO Council for Growth. “The million-dollar question in this field is ‘Can you achieve hard outcomes by addressing the non-medical issues that affect patients’ daily lives?” she said.

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Asking patients their opinion on what they need to improve their health has allowed the program to provide flexible, customized support to address non-medical issues that might otherwise hinder outcomes, such as mental health problems, social or economic issues or relationship difficulties among family members. As simple as the question might seem, Kangovi points out that it gets patients more fully involved in their own care. “It elicits what patients want and it gets buy-in,” she said.

Other recent studies have reported cost savings and improved outcomes from expanding care into patients’ homes and offering behavioral health support to improve post-acute care. The likelihood of a patient who met with a worker from the IMPaCT model visiting a primary care practitioner for follow-up within two weeks of discharge was 52% higher than average, according to the case study.

The study’s success has generated enough interest from other healthcare programs that the program has recently prioritized making its model more broadly available via an online learning system.