1. Reid-Ponte, Patricia DNSc, RN, FAAN, NEA-BC


In this column, Dr J. Margo Brooks Carthon discusses her work to support access to quality healthcare services for patients in minority and less than affluent circumstances. Dr Brooks Carthon has worked in a collaborative known as THRIVE. The program has offered intensive wrap-around clinical and social services and has positively impacted the wellness of chronically ill individuals.


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Reid-Ponte: Can you describe what brought you to your role as an innovator in healthcare delivery focused on ensuring equitable access to care for all?

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Brooks Carthon: I practiced as a registered nurse in an acute care setting before attending the University of Pittsburgh for my Adult Health Psychiatric Advanced Practice Registered Nurse (APRN) education. Later, I worked in a community health center and after that in a private practice in an affluent community. These experiences helped me witness firsthand that high-quality care was not available to all. During my clinical experiences I noticed that the impact of the social dimensions of health such as the ability to get transportation to and from a visit, access and affordability of medications, food insecurities, and housing could be more pressing than chronic illness.

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As an APRN working in practice, I had the capacity, time, and resources to help patients with holistic needs, not just treat their medical condition. Many patients and their families really need this additional support but don't uniformly receive it-particularly individuals from minorities or low-income communities. In many cases, these individuals and their families feel as though they are in a foreign land, and navigating the complex health system is a challenge. Routinely, nurses and other healthcare providers don't have the time to address the social determinants of health that patients and families face because of competing time demands and a lack of organizational commitment to addressing health related social needs. While in a postdoctoral fellowship in the Center for Health Outcomes & Policy Research at Penn, I learned about the ways that resources such as adequate staffing and supportive clinical work environments influence nursing care. How we structure our care and resources positions nurses to know and understand the clinical and social needs of the people our communities.


Reid-Ponte: It seems that you integrated 2 challenges, 1st, the need to provide structures, resources, and support for nurses so they can identify and are able to meet the needs of socially at risk patients, many of whom have chronic disease burdens and to assure patients and their families are supported in leading healthy lives with chronic illness.


Brooks Carthon: That's right. Nurses are educated to provide holistic care. To effectively integrate social and clinical needs into care planning, nurses must practice in settings that provide the time and resources to engage in supportive preventative care. They must be allowed to practice to the top of their licenses. I have had the incredible opportunity to work with a team to create such a program with partners at Penn Medicine and would love to see this program replicated.


Reid-Ponte: I recently read about the human-centered design principles that you and leaders at the health system used to generate and iterate a program to support low-income chronically ill patient populations. Can you describe the elements of the program?


Brooks Carthon: We started the pilot project called THRIVE through an academic-clinical-community collaboration with Penn Presbyterian Medical Center (PPMC), Penn Medicine at Home, the Penn Schools of Nursing and Medicine, and community partners and seed money from the healthcare system. THRIVE offers intensive wrap-around clinical and social services. Our focus on Medicaid-insured individuals was purposeful due to evident disparities among this populations. PPMC serves more than 300,000 residents of West Philadelphia, approximately 75% of whom are Black, 58% of whom are insured by Medicare, and 24% of whom are insured by Medicaid. Early in our work, we noted that over 21% of Medicaid-insured individuals experienced a 30-day readmission and 17% experienced an emergency department (ED) visit, compared to 6% of commercially insured individuals who were readmitted and 4% who experienced an ED visit. The Design Thinking process helped us to take a deep dive into the experiences of Medicaid-insured individuals, who are disproportionately racial and ethnic minorities, following discharge, and to explore the processes supporting them. By emphasizing the experiences and needs of individuals, while evaluating healthcare system processes, we were able to identify an "opportunity gap" and that's how THRIVE was born. With THRIVE, Medicaid-insured individuals are identified while hospitalized and referred to home care services (home care nurses complete their initial assessment within 48 hours of discharge). During the visit, nurses provide chronic disease management and patient education. Participants are followed for ongoing clinical supervision by the discharging hospital-based physician for up to 30 days postdischarge. The THRIVE team offers intensive coordination via weekly interdisciplinary case conferences for 30 days postdischarge. We facilitate referrals to postacute services, including substance abuse services, housing support, and transportation. In the past 2 years, over 400 individuals have received THRIVE services.


Reid-Ponte: So, you never received federal or foundation funding to implement this program?


Brooks Carthon: Not yet; however, we are planning to. It would have taken years for us to develop a proposal and attain funding for a traditional research project. We saw the needs, we knew the problems, and we had ideas about how to address it. It's been a work in progress while delivering outcomes. Fewer patients are readmitted, more patients are living healthily with chronic disease, as well as other outcomes: fewer ED visits following discharge, increased posthospitalization visits with primary care and specialty providers, and more connections to behavioral health resources and social services.


Reid-Ponte: Do you believe the health disparities that existed before the pandemic were as clearly understood when this program started?


Brooks Carthon: It has been obvious to me for quite some time that access to care for minoritized individuals and people from economically disadvantaged backgrounds, has been variable. The pandemic made it possible for others to see this. Suddenly, what have known and have been working for, equal access to high-quality care, is apparent and there is a wave of desire to eliminate health disparities and other forms of discrimination and social injustice.


Reid-Ponte: What prompted you to want to become a nurse in the first place?


Brooks Carthon: Two women in the church I attended with my family as a young person inspired me. I saw them in action in the community making a difference in my life and those of others. I said to myself, "I want to do that someday." Here I am.


Reid-Ponte: That's so moving and makes me think of 2 women, who weren't nurses but who had influence in my life when I worked as a hospital kitchen aid in high school. They taught me about teamwork and caring about doing a good job to help others. I'll never forget them. What would you like JONA readers to think about based on your innovative work?


Brooks Carthon: To the readers: You have the power to transform how people experience the healthcare system, particularly those who have been marginalized. You can move mountains through your will and ingenuity to assure equity, social justice, and compassion. Nurses know what the work is, know how to improve systems and structures, and must be a part of the solution to drive equitable care.