This funding will support a pilot program designed to better support low-income patients of color, who are more likely than other patients to be readmitted to the hospital after being discharged. The pilot will focus on patients undergoing colorectal surgery, identifying those considered at high risk, and creating a section in the electronic health record system to identify and track them until they are fully recovered. The pilot will include documenting nonmedical factors that can lead to adverse outcomes – such as food insecurity, unstable housing, and not having a primary care provider – as well as steps taken to address those challenges. In addition, a community health worker will be added to the colorectal patient care team to help patients prepare for surgery and support the patients through the recovery process. The pilot will also include using a system of protocols to prepare patients for surgery and recovery that are designed to improve post-surgical outcomes.
Other Grants: