UPMC Prescription for Wellness: Lessons Learned From 10 Years of Progress and Innovation

Program Description and Data Sources

Providers select from a robust order set offering support across lifestyle improvement, chronic and complex medical conditions, behavioral health, pharmacy intervention, pediatrics, maternity, remote monitoring, and health-related social needs (please see Appendix A for the full PFW order set). Within the order set, providers can also specify the modality in which their patient-member would like to engage with UPMC HP (telephonic or digital). Additionally, technology integration enhancements allow for feedback notes to be sent to prescribing providers, offering a comprehensive summary of their patients’ engagement with UPMC HP’s clinical teams.

Between July 2014 and December 2024, 3,145 providers across 80 specialty types used PFW, completing 103,008 prescriptions for UPMC HP services for more than 80,836 UPMC HP patient-members. Looking at the most recent 5 years of prescriptions, the average age of patient-members receiving a PFW was about 48 years old (about 10 years older than the average age of UPMC HP members) and roughly 70% of prescriptions were written for female patient-members (about 52% of all UPMC HP members are female). Just more than half of prescriptions were written for patient-members identified as “rising risk” or “high-risk” by UPMC HP analytics (ie, have 2 or more chronic physical, behavioral, or social health challenges and/or are predicted to utilize avoidable hospital-based care in the next 12 months), whereas only 27% of overall membership falls into these categories. These descriptive statistics suggest that providers complete a PFW for patient-members who trend a bit older and more female than UPMC HP’s average membership and write prescriptions more often for members with more health risks. This is encouraging, because for the more than 80,000 UPMC HP patient-members with a PFW referral between July 2014 and December 2024, UPMC HP was able to reach 75% of them, and more than 60% of those who were reached engaged in services (ie, completed at least 1 clinical session with UPMC HP clinical staff), resulting in over 200,000 clinical sessions. The prescribing provider receives a feedback note documenting the outcome of UPMC HP outreach efforts, including whether the patient-member was reached, declined services, engaged in services, or was unable to be reached. Patient-members also receive a copy of the order outcome through their patient portal.

The most significant change to the platform since its inception happened in 2021 when text messaging was integrated into the PFW workflow, creating a direct channel to connect patient-members digitally to UPMC HP clinical services. Between August 2021 and December 2025, over 25,700 text messages were sent to patient-members. When comparing 2024 engagement rates (ie, patient-member willingness to discuss provider-prescribed UPMC HP services for all members who received a PFW in 2024) among patient-members who received a PFW from their provider and an accompanying text message to engagement among patient-members who received an unsolicited outreach in 2024 (ie, outreach from UPMC HP to offer supportive services without an associated provider recommendation), there was a 550% difference in engagement among those who had received a PFW with an accompanying text message, highlighting the impact of the provider prescription on patient-member willingness to engage with UPMC HP services.

Implications

PFW has grown in scale and impact over the past decade, and the authors continue to work with the provider community to optimize the process and its results. The authors have worked to increase the number of prescribing providers and to make prescribing more convenient by exploring technological enhancements to support utilization (ie, best practice alerts, auto-referral based on established clinical criteria). Improvements to how prescriptions and their outcomes are monitored have been made with a PowerBI dashboard that enables month-over-month tracking of metrics such as provider- and member-level data, as well as outreach (frequency, modality), and engagement data (assessments completed, clinical sessions). The authors have built infrastructure to enable a learning community among administrative and provider “champions” who write the most PFW orders. In biannual meetings, these champions provide feedback and input on strategic changes to the platform, such as new services to include in the order set and ways to improve feedback to providers.

While much of the PFW process is generalizable, the authors acknowledge several limitations. The PFW results described here are from within a single integrated delivery and financing system and may not be fully generalizable to settings with different payer–provider relationships, technological infrastructure, or organizational cultures. Further, the platform utilization and patient-member engagement data reported here are observational, and the providers who write PFWs and the patient-members who subsequently engage in UPMC HP services are likely systematically different than providers who do not write PFWs and patient-members who do not engage. Without a randomized design, we cannot make a causal link between observed increases in patient-member engagement in UPMC HP services and use of the PFW platform.

Prescription for Wellness demonstrates how principles established in the literature on physician engagement, workflow-embedded referral systems, and evidence-based interventions can be operationalized and sustained at scale within a real-world health system. As health systems increasingly seek scalable approaches to address chronic disease burden and health-related social needs, models such as PFW offer a transferable framework for integrating referrals to evidence-based services into routine clinical practice while strengthening collaboration across organizational boundaries.^1,2

Over the past decade, the authors have learned that a “people, process and technology” framework is key to continually optimizing deployment and expansion. Some key lessons learned include that provider utilization is contingent on effective collaboration with key stakeholders in leadership, practice management, and at the office staff level. Embedding an electronic ordering method within a practice’s EMR and office workflows is critical. Continual surveillance of utilization and impact are necessary for supporting continuous quality improvement. And keeping PFW focused on the goals shared across provider and payer –working together to facilitate patient-members receiving the full complement of service and support their care team and insurer can provide – ensures PFW supports our shared mission to improve the health of our patient-members.