Original Source: Penn Medicine
Written By: Abby Alten Schwartz
Mike Desalis was used to juggling a lot from his South Philly home. As a 61-year-old with multiple ongoing medical conditions, he did a good job of organizing his medications, scheduling doctors’ appointments, and following through with recommended tests. But in the last year, he experienced a cascade of health events that proved too overwhelming to handle alone.
In late summer of 2024, Desalis 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.
In February 2025, Desalis began blacking out and falling at home, prompting him to seek emergency care at Penn Medicine’s Pennsylvania Hospital. “I didn’t know if I was having another heart attack,” he said.
Desalis was admitted. And that’s when his case was picked up by an innovative program at Penn called Thrive. All those balls he’d been juggling? The Thrive team was there to catch them.
Assessing needs, bridging gaps
Margo Brooks Carthon, PhD, RN, FAAN, executive director of Thrive, 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.
“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,” said Brooks Carthon, who is a professor of Nursing at the Penn School of Nursing.
For example: A patient has a follow-up appointment but no transportation. Or they use a CPAP machine for sleep apnea, but their electricity gets turned off. One key function of Thrive is arranging for the medical services and social support patients need, whether through Penn Medicine or a community resource.
Another important function is improving continuity of care. Marsha Grantham-Murillo, DNP, RN, a Thrive nurse case manager with Penn Medicine at Home, said that collaboration between the hospital care team and the home care team is crucial.
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.
Personalized support
When Desalis was admitted to Pennsylvania Hospital after blacking out in February, doctors attributed his symptoms to an exacerbation of chronic obstructive pulmonary disease (COPD). He went home after a brief stay. Days later, he was back in the emergency room—this time for longer.
Grantham-Murillo explained that COPD can cause carbon dioxide retention, leading to breathing issues and other complications. Hypertension, a sparse diet, and insufficient assistance at home also likely contributed to his readmission.
Desalis lives alone with his emotional support dog. For years, he’s had a home health aide (not through Penn), but based on his condition, the six hours of daily assistance he was receiving weren’t enough.
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.
Every Thrive patient gets a social worker visit at the start of their home care. When Desalis’ social worker met with him, she recognized he needed additional home health aide hours, helped him apply, and advocated on his behalf for insurance approval.
The social worker noted that Desalis was using oxygen from a tank versus a concentrator, which patients typically use. A concentrator removes nitrogen from the air, leaving a purer concentration of oxygen. The problem with having tanks in the home was that Desalis smoked—a dangerous combination.
The Thrive team consulted his provider who decided it was safer to eliminate the supplemental oxygen—a decision Desalis favored as well.
“I use the inhalers and do my breathing treatments,” he said.
The social worker asked Desalis questions to uncover any social barriers to health. He doesn’t drive, so she connected him with Modivcare, a non-emergency transportation service that gives him rides to appointments, the grocery store, Masonic meetings, and more.
She helped him schedule doctors’ visits and coordinated with his Thrive team to have durable medical equipment delivered to his home, including walkers (one with wheels for downstairs, another without wheels for upstairs) and a portable commode.
Grantham-Murillo said social workers often discover things the patient didn’t know they were entitled to. She pointed out that while the Thrive team “hovers” over a patient for 30 days, any services they arrange, such as therapy or skilled nursing, continue for as long as they’re needed.
Keeping a watchful eye
Desalis works with a Penn Medicine at Home physical therapist in his home to increase his lower limb strength and improve his balance. He’s worked with her many times over the years, and she communicates well with other members of his care team regarding his progress as one of the interdisciplinary team members who connect through Thrive.
Under Thrive, a Penn Medicine at Home nurse visits weekly to examine Desalis, check his vitals, and find out how he’s faring. She asks about pain levels and reviews his medications, which Desalis takes pride in managing himself.
“I take care of my medication,” he said. “I know what it does, what each pill looks like.”
On days the visiting nurse isn’t scheduled, Desalis still benefits from the watchful eyes of his care team. He has daily health check-ins via telemedicine, using the tablet device Penn provided to enter his weight, blood pressure, pulse-ox, and other information and to answer a few simple questions. There’s even a help button if he’s not feeling well and wants a provider to call him.
Proving impact, Thrive expands
Thrive started as a pilot project in 2019 at Penn Presbyterian Medical Center, supported by a grant from Penn’s Leonard Davis Institute for Health Economics. In early 2023, the Rita and Alex Hillman Foundation funded a randomized trial of Thrive services at Pennsylvania Hospital.
In that study, Medicaid-insured patients who received Thrive plus home care had 50 percent fewer readmissions at 30, 60, and 90 days compared to those with home care only.
Data from other Thrive studies show additional ways the program is making an impact after hospitalization, including decreased emergency department use, increased patient satisfaction, and improved quality of life.
Later in 2023, the Agency for Healthcare Research and Quality (AHRQ) provided a generous grant that allowed Thrive to conduct a clinical trial at HUP – Cedar Avenue, adapting the program to meet the needs of eligible patients discharged from this Southwest Philadelphia community hospital who are also diagnosed with serious mental illness. The program has since expanded to HUP’s main Spruce Street location.
When a patient is dealing with a mental health condition, it can affect their ability to refill prescriptions and comply with medical orders related to a physical illness. The AHRQ grant enabled the Thrive team to collaborate with mental health professionals to determine how to best support people with co-occurring mental illness.
For Desalis, who sought help for mood and anxiety symptoms last summer, the overall mental health support he’s received through Penn Behavioral Health has been an important part of his care. Initially, Desalis was referred to Mila Tamminga, MD, now a fourth-year psychiatric resident at Penn, for medication management. After they met, he became a weekly therapy patient, too.
Though her involvement with Desalis predated his participation in Thrive, Tamminga has noticed the increase in coordinated care since the team stepped in. Now the responsibility of managing all of the supportive services he needs doesn’t rest solely on Desalis or one particular doctor.
“He was really doing a lot, trying to keep track of that himself, and he did a great job—but there are naturally going to be things he can’t do himself or that are tough for him to navigate,” she said.
Case management from a bird’s-eye perspective, combined with collaboration among the various medical and service providers involved in a patient’s case, results in care that’s proactive versus reactive. Holistic versus fragmented. Everyone focused on helping that patient thrive.