UPMC’s Enhanced Care Program Provides High-Quality Care for High-Needs Patients

Basic medical care isn’t enough for every patient, especially for those who struggle with complex health problems.

The Enhanced Care Program (ECP) at UPMC Montefiore, a program of UPMC General Internal Medicine, is designed to help those complex patients. The primary care clinic aims to coordinate patient care across services to facilitate access and minimize duplication.

Once referred, patients meet for an initial one to two-hour visit for a patient-centered medical and psychosocial interview conducted by the program team. Both medical and mental health providers are then notified of the patients’ enrollment in the program.

Continuum of Care

Patients are typically seen at minimum once a month and then contacted by phone. The multidisciplinary care team includes:

• Licensed social worker.
• Nurse care managers.
• Pharmacists.
• Physicians.
• Psychiatrists.
• Spiritual care chaplain.
• Therapists.

What Services Does the UPMC Enhanced Care Program Offer?

The following services may be provided through the program in the clinic or at a patient’s home:

• Primary care.
• Hospital discharge planning.
• Treatment modalities for emergency department diversion.
• Medication adherence monitoring.
• Linkage to appropriate mental health services.
• Linkage to substance abuse community resources.
• Navigation and advocacy for patients requiring social security disability.
• Securing safe housing.
• 24/7 phone access to our care team.

The team provides continual communications with providers and other supports, including, but not limited to:

• Mental health service coordination.
• Home care.
• Home health aides.
• Waiver service coordinators.
• Personal care homes.

This communication occurs after every visit.

“What sets the UPMC Enhanced Care Program apart is its personalized, team-based approach to care,” says Jodie Bryk, MD, medical director, UPMC Enhanced Care Program. “Through the program, patients and providers benefit from improved continuity and quality of care for high-needs patients, improved patient experience and satisfaction with care, reduced number of emergency department admissions, and a patient-centered treatment plan.”

Eligibility

Eligible patients must meet the following criteria:

• Have had four or more emergency department visits over the past year.
• Preventable hospital admissions.
• Age 18 and over residing in Allegheny County.
• UPMC Health Plan member.
• Referred by a primary care provider or other physician.

To refer a patient to the UPMC Enhanced Care Program, call 412-925-5875 or email us for more information.