Achievement Awards Spotlight: Penn Highlands Mon Valley

August 11, 2023

HAP's annual Achievement Awards honor hospitals and health systems for their innovation, creativity, and commitment to patient care. The Achievement Awards showcase and share member hospitals’ and health systems’ successful programs and best practices.

This year, Penn Highlands Mon Valley received the Excellence in Care award for its outstanding project to address patients’ barriers to health, improve outcomes, and reduce preventable readmissions.

Here’s what you need to know:

• The challenge:  Across the U.S., one in five patients is readmitted to the hospital within 30 days of discharge. This highlights the opportunity to redevelop discharge planning to help prepare patients and support their care after leaving the hospital.
• Taking action:  Penn Highlands Mon Valley developed a no discharge process that addresses care gaps and social determinants of health (SDOH).
  • An interdisciplinary team, consisting of nurses, a behaviorist, and navigators, uses an assessment to identify SDOHs and patients at high risk for readmission.
  • The interdisciplinary team then completes home visits and virtual follow up as needed following newly developed care protocols for high-risk patients.
• Results:  The hospital has made significant progress in readmission rates for high-risk patients, received outstanding patient satisfaction feedback, and noted improvement in other key post-discharge health metrics.
• Key steps:  The team has a complex care committee that meets with inpatient social services, care management, the Community Care Network medical director, and the inpatient behavioral unit. This group aims to address social determinants of health, prevent errors, remove barriers to care, and reduce preventable readmissions.
• Quotable:  “The mission of the Community Care Network is to change the culture of health care through a no discharge process, providing health care and wellness services in the home or post-acute setting and in partnership with the community,” the team noted in its entry. “The vision of the Community Care Network is a patient centered, integrated model of care to improve health care and wellness services to our community.”

Congratulations to Penn Highlands Mon Valley for its tremendous dedication to improve the post-discharge process and reduce preventable readmissions.

Questions about the HAP Achievement Awards may be directed to HAP Member Services at (717) 561-5359.