Grant Application

Carole Taylor, MSN, RN, of Community Care Behavioral Health in partnership with James Schuster, MD, MBA, Marian Essey, RN, Jane Kogan, PhD

Proposed Innovation

Identify patients with complex needs, including those with at least three readmissions within the prior year, and implement a bridging strategy to reduce unnecessary readmissions to medical hospitals.


A care management team comprised of RNs and Social Workers from within the Insurance Services Division (ISD) met face-to-face with patients on the medical units of three UPMC hospitals, beginning with UPMC McKeesport. Team members conducted personal interviews with patients to determine what brought them to the hospital and identify their interests and needs — including housing options, transportation availability, or the financial impact of follow-up care — and other concerns within their home or community that may be a barrier to their health and wellness. The information was then shared with the hospital treatment team, including the physician, to better address needs following hospitalization.

In addition, the care managers were able to work with and intervene with individuals who identified the social determinants (e.g., lack of food in the home with referral to the Food Bank) that may have kept them from achieving recovery from their illness. Patients were followed for 90 days by care managers to ensure engagement and stability with additional work completed on the individual’s specific ongoing Wellness and Recovery Action Plan.


This project resulted in a 10 percent decrease in the 30-day readmission rate. The next step would be to expand the project for use by the Community Teams across UPMC hospitals.