Abstract 17449: PACT: Preventable Admission Care Team: A Unique Approach to Reducing 30 Day Readmissions
Background/Significance: There is a national mandate to prevent hospital readmissions. In 2009, CMS began publicly reporting 30-day readmission rates for patients hospitalized with pneumonia, acute myocardial infarction, and heart failure. Multiple factors contribute to avoidable readmissions, and can result from: poor quality care, premature discharges, poor coordination and communication between patient and providers.
Program: Mount Sinai Hospital (MSH) has created The PACT Program, with the goal of reducing 30 day readmissions. PACT is internally funded and consists of 4 social workers (SW) in the hospital and 2 NP's and 1 SW in the internal medicine clinic. Patients at high risk of readmission are identified in the hospital based on their readmission history. The SW performs a 75 minute patient/caregiver psychosocial assessment. A five week post-discharge care coordination plan follows by the same enrolling SW. This includes intensive phone follow-up and home visits to appraise home safety, environmental hazards, family involvement, medication compliance, nutritional/dietary assessments. Patients with fragmented primary care are referred to the PACT clinic.
Patient Profile: Age range from 19-99; 52% are 65+; 8% 85+; 52% women; 48% male; 38% are African-American; 32% Hispanic; 43% have congestive heart failure, 45% diabetes; 16% dialysis, 21% documented mental illness; 66% greater than 2 co-morbidities; 85% Medicare and/or Medicaid; 87% have a family caregiver.
Results: 6 month (see table)
Conclusions: PACT is engaging the most challenging patients and is successful in reducing 30,60,90 day readmissions. PACT patients represent a diversity of age, gender and ethnicity, are medically complex, enriched in cardiovascular disease and diabetes. PACT includes non-english speaking patients with cognitive impairment, mental illness, which other transitional programs have excluded. The model is replicable, sustainable, and improving quality of care.
- © 2011 by American Heart Association, Inc.