After the hospital, support to help patients thrive at home
A Penn-grown program offers low-income patients extra support after a hospital stay—with virtual teams knitting together a safety net to reduce readmissions.
2 min. read
In the last year, Mike Desalis experienced a cascade of health events that proved too overwhelming to handle alone. In late summer of 2024, he was diagnosed with tonsil cancer and underwent treatment at Penn Medicine’s Abramson Cancer Center that stretched to November. Then, just after Christmas, while riding in his brother’s car on their way to the Jersey Shore, he suffered a heart attack, necessitating emergency intervention and a hospital stay in New Jersey. Desalis was admitted to Penn Medicine’s Pennsylvania Hospital after blacking out and falling at home. That’s when his case was picked up by an innovative program at Penn called Thrive.
Margo Brooks Carthon, executive director of Thrive, has co-led the program’s development to help low-income patients with multiple chronic conditions transition better from the hospital to home.
Factors such as poor communication between inpatient and community-based providers, as well as health-related social issues like food insecurity or lack of transportation, are known to negatively impact recovery. Thrive, operated in partnership between Penn Medicine at Home and Penn Nursing, addresses those factors by providing 30 days of intensive care coordination and virtual nurse case management to eligible Medicaid-insured patients following a hospital stay.
Physical therapist Jana Barmasse reviews information on a tablet that Mike Desalis uses to report health updates to his care team.
(Image: Courtesy of Penn Medicine News)
“With Thrive, we assess everyone for their social needs, recognizing that it’s in the interface between the social and the medical where people really have the potential to fall through the cracks,” says Brooks Carthon, a professor at Penn Nursing.
Traditionally, the hospital provider’s role ends when the patient is discharged. Under Thrive, they stay involved after the patient is home—a bridge between the 24/7 attention they received in the hospital and the nurse-led support they receive at home. If there’s no primary care provider on record, the hospitalist will oversee orders while the home care nurse helps the patient get established with one.
Each Thrive team includes a virtual nurse case manager, social worker, home care nurse, and discharging provider. These and other interdisciplinary partners join a weekly online meeting to discuss each patient and ensure their needs are met, forming a virtual safety net to catch anything that might be missed.
As of October 2025, Thrive is integrated into the services provided through Penn Medicine at Home for eligible patients leaving Penn Presbyterian Medical Center and Pennsylvania Hospital. A research grant currently funds an extension of the programs at the Hospital of the University of Pennsylvania (HUP) and HUP—Cedar.
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