CarePath – ED Diversion & Community Connection

Role:  Program Manager

Emergency departments were becoming the landing spot for patients facing challenges far beyond medical needs, issues like food insecurity, housing instability, and behavioral health crises. Recognizing that many of these visits were preventable, I led the development of the CarePath program to better identify and support patients with underlying social needs.

We designed a process within the EMR that automatically flagged patients for a social work screening based on their intake information. This ensured that those who might benefit from community-based services were connected to a social worker during their visit, not after discharge. Once identified, patients were linked with programs addressing food access, housing support, or behavioral health follow-up.

A key insight came from data trends showing repeated ED visits for wound care—an issue often driven by lack of outpatient follow-up. That discovery led to the creation of a dedicated wound care clinic, offering patients a clear and sustainable path to treatment outside the emergency setting.

Impact:The CarePath initiative successfully reduced avoidable ED visits, improved resource utilization, and delivered tangible improvements in patient well-being. More importantly, it helped shift the system’s approach from reactive to preventive, meeting patients where they were and connecting them with the right support for long-term stability.