A conference at Sacred Heart Hospital on Wednesday gave health and community groups a chance to talk about how to best serve the community's sickest patients.
Many of the people at the meeting are with organizations that make up the Lehigh Valley Super Utilizer Partnership.
"The program that we primarily work with, they're called super utilizers, people who are admitted to the hospital more than three or four times a month, they have various chronic conditions, they are taking six or more medications," said project manager Manuel Ayala.
"We know that to provide good care, it's more than just dealing with the body. It's dealing also with the spirit, mind," he said.
The conversation focused on the barriers patients face and how good health care has to be a collaboration.
"There's a lot of barriers, sometimes it might be transportation," said Angela Garner, a clinical social worker.
"When people are chronically ill it's very easy to get isolated from the community and that's one of the goals of this program is to help people either connect or reconnect with the community," said Lois Lewis with Congregations United for Neighborhood Action.
People in attendance also discussed what care givers should focus on to provide the best care. They work with patients and their families to become more self sufficient and better manage their conditions to hopefully cut back on hospital visits.
"Whenever we can stop repeated omissions to the hospital for the same chronic disease, society is saving money, the cost of health care comes down but more important the patient stays well longer," said John Nespoli, Sacret Heart president and CEO.
"When someone spends a lot of time in the hospital then that means there are things that are not being tended to at home and in many cases we've learned of patients who get discharged from the hospital, they go home, they don't have anything in their refrigerator," said Ayala.
In a case like that, he said they can refer people to food pantries and help make sure they have food.
Lewis said, "That's a benefit to everybody if we can get people back into the community, be productive and stay out of the hospital."