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The Preventable Admissions Care Team (PACT): A Social Work-Led Model of Transitional Care
Maria Basso Lipani1, Kathleen Holster1, Sarah Bussey1
1a Department of Social Work Services , The Mount Sinai Hospital , New York , New York , USA.
Insights
The Preventable Admissions Care Team (PACT) model reduced hospital readmissions by 43% and emergency visits by 54% in high-risk patients. This social work-led transitional care program improved patient follow-up appointment adherence.
Area of Science:
- Healthcare Management
- Social Work in Healthcare
- Patient Transitional Care
Background:
- High-risk patients face significant 30-day readmission rates.
- Psychosocial factors are key drivers of preventable hospital readmissions.
- Existing care models often lack comprehensive psychosocial support during transitions.
Purpose of the Study:
- To evaluate the effectiveness of the Preventable Admissions Care Team (PACT) model.
- To reduce 30-day readmissions and associated healthcare utilization in high-risk patient populations.
- To assess the impact of a social work-led transitional care intervention.
Main Methods:
- Implementation of the Preventable Admissions Care Team (PACT), a social work-led transitional care model.
- Comprehensive bedside assessments to identify psychosocial readmission drivers.
- Patient-centered action plans involving phone calls, navigations, and home visits post-discharge.
- Enrollment of 620 high-risk patients from September 2010 to August 2012.
Main Results:
- A 43% reduction in inpatient utilization among PACT enrollees.
- A 54% decrease in emergency department visits for PACT participants.
- High adherence to follow-up appointments: 93% scheduled within 7-10 days, 90% attended.
Conclusions:
- The social work-led PACT model significantly reduces hospital readmissions and emergency visits.
- PACT demonstrates success in improving post-discharge care coordination and patient engagement.
- The model's effectiveness has secured further funding for population health management interventions.
Abstract:
In 2010, the Preventable Admissions Care Team (PACT), a social work-led transitional care model, was developed at Mount Sinai to reduce 30-day readmissions among high-risk patients. PACT begins with a comprehensive bedside assessment to identify the psychosocial drivers of readmission. In partnership with the patient and family, a patient-centered action plan is developed and carried out through phone calls, accompaniments, navigations and home visits, as needed, in the first 30 days following discharge. 620 patients were enrolled during the pilot from September 2010-August 2012. Outcomes demonstrated a 43% reduction in inpatient utilization and a 54% reduction in emergency department visits among enrollees. In addition, 93% of patients had a follow-up appointment within 7-10 days of discharge and 90% of patients attended the appointment. The success of PACT has led to additional funding from the Centers for Medicare and Medicaid Services under the Community-based Care Transitions Program and several managed care companies seeking population health management interventions for high risk members.
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