Improving Outcomes among Medically Complex Populations in a Safety Net Setting: A Workgroup Proposal

Pilot Project

Improving Outcomes among Medically Complex Populations in a Safety Net Setting: A Workgroup Proposal

Abstract: Medically complex, socially‐at‐risk populations experience relatively poor outcomes during and following a hospital admission, including higher rates of readmissions, more frequent visits to the emergency department, and lower reports of satisfaction with care. Acknowledging these persistent and poor outcomes, we propose a workgroup comprised of clinicians, researchers, and faculty members from the UPENN Schools of Nursing and Medicine and the Penn Presbyterian Medical Center, to inform initiatives to reduce disparities and improve care outcomes among vulnerable populations. The goals of our workgroup are to: identify metrics of social risk and medical complexity currently included in the electronic record, develop a methodology to “hot‐spot” the acute care space and take steps to use this data to isolate which units/service lines/diagnostic conditions have disproportionate shares of medically complex, socially‐atrisk populations; uncover barriers or resources that influence successful care transitions from hospital to home, and determine outcomes of importance to the health care entity (e.g., readmissions, LOS, costs). Results of our workgroup will be used to inform future research endeavors to test targeted interventions to improve outcomes and care transitions for medically complex, socially‐at ‐risk patients.