Managing High-Risk Patients in the McKeesport Community

Grant Application

Alexander Hill, MHA, UPMC McKeesport

Proposed Innovation

Federally designated as a “medically underserved area,” the McKeesport community has a lower median household income and a high percentage of families living below the poverty level. Many residents are unaware of health resources available or don’t know how to access them. Those who are ill often have poorly managed medical conditions resulting in frequent emergency department visits and high rates of readmission; they don’t know where to go for the care they need.

The goal of this project is to improve the transition of high-risk patients from hospital to home by matching them with a community health worker to manage their care following their discharge.

Improvements in Action

In this innovative project, a full-time, hospital-based community health worker will work with high-risk patients following discharge from the hospital or emergency room. This worker will serve as a point of contact for patients and their families, checking in frequently to ensure that patients have returned home safely, received prescribed medications, had basic needs met, and have an active and engaged caregiver available.

Intended Outcomes

Providing close monitoring and management of these high-risk patients following discharge is expected to improve their transition home, reducing readmissions and avoiding unnecessary emergency department visits. In addition, having a full-time point person available is expected to increase accountability and improve communication to ensure more patients receive the appropriate care they need.