Principal Investigator: Shreya Kangovi, MD
Abstract: Dually eligible individuals, who qualify for both Medicare and Medicaid, are among the poorest and most
vulnerable patients in the American health care system (1). As a result, these patients are particularly vulnerable to
socioeconomic factors which can impede the successful transition from hospital to ambulatory care (2). They are more
likely than other patients to lack timely primary care provider (PCP) follow-up, to return to the ED following hospital
discharge, and to be readmitted to the hospital (3, 4).
Penn Medicine has partnered with Spectrum Health Services (SHS), a West Philadelphia community health
center, to develop The Patient-Centered Transition (PaCT) Project. The PaCT Project utilizes trained CHWs to provide
social support, navigation and advocacy to socioeconomically vulnerable patients who are being discharged from the
The Hospital of the University of Pennsylvania (HUP) and Penn Presbyterian Medical Center (PPMC). The CHWs, or PaCT
Partners, will help patients to overcome the challenges of transition, including arranging primary care provider (PCP)
follow-up, filling medication prescriptions and obtaining referrals to community-based social services. The PaCT Project
is an established care transitions intervention that currently targets uninsured and Medicaid patients.
In this application, we propose a pilot randomized controlled trial of the Patient-Centered Transition (PaCT)
Project in a dually eligible Medicare population. As our primary outcome, we will examine the effect of PaCT on rates of
primary care follow-up. We will also examine the effect of PaCT on secondary outcome variables including patients’
satisfaction with the experience of transition, medication adherence, self-rated health, and ED revisit or inpatient
readmission within 30 days after discharge.