Grant Application

Thuy Bui, MD, UPMC Presbyterian 

Proposed Innovation

Hospital readmissions are influenced not only by the health of patients and quality of care they receive, but also by their access to resources — or social needs — such as transportation, income, housing, health insurance, and social support. This innovative Social Needs Action Program project aims to reduce readmissions by identifying and addressing the social needs of vulnerable patients at the time of their discharge from UPMC Presbyterian or UPMC Montefiore.

Improvements in Action

Through this project, the SNAP team will use a bedside tool to screen patients from Pittsburgh’s low-income Homewood area for difficulties with transportation, healthcare access, safety, and other needs. Patients will then be connected with social services and other community resources. A referral tracking tool also will be used to determine how those needs were prioritized by the patients and providers, and if those needs were met.

Patients will be contacted following discharge to ensure those connections were made. In addition, team members will conduct home visits when appropriate and coordinate care with each patient’s primary care provider, other health care providers, and health plan.

Intended Outcomes

The SNAP project is expected to result in a decrease in 30-day readmissions and emergency department visits. The team also hopes to demonstrate the feasibility of using community health workers to address social needs for discharged patients. Ultimately, the team believes the project will serve as a model that hospitals can use system-wide to link vulnerable patients to essential resources so they can lead healthier lives.