Clinical pathway explores community-based collaborations, improves health equity

The University of Pennsylvania School of Nursing introduced the Thrive clinical pathway Aug. 18 to improve health equity and support those who experience adverse outcomes resulting from complex chronic illnesses, poverty and inequality.

Thrive clinical pathway program participants receive a visit from a home-care nurse within 48 hours of discharge from a hospital. They also receive clinical support from their discharging physicians and social workers. Additional clinical care services are provided as needed, including occupational therapy, physical therapy and community health worker services.

Early results from the new clinical pathway show that participants had fewer 30-day emergency department visits and fewer 30-day readmissions than those not enrolled in the program.

University of Pennsylvania Associate Professor of Nursing J. Margo Brooks Carthon, PhD, said the results are clinically meaningful and may be linked to an intentional focus on addressing the social determinants of health.

"Through both home-care services and continued clinical oversight by hospital-based physicians, we are able to intensify the clinical services provided in the aftermath of an acute hospitalization while also attending to social needs that are often unaddressed after hospitalization," Dr. Brooks Carthon said.

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