The GeriPACT Initiative to Prevent All-Cause 30-Day Readmission in High Risk Elderly.

Area of Science:

• Healthcare Management
• Quality Improvement
• Geriatric Care

Background:

• Suboptimal care transitions and poor coordination increase adverse events.
• The National Transition of Care Coalition advocates for continuous management post-discharge.
• Patient-centered medical homes show promise in improving coordination and reducing readmissions.

Purpose of the Study:

• To evaluate the impact of a quality improvement initiative on 30-day all-cause readmissions.
• To assess the effectiveness of proactive telehealth and team-based care in managing geriatric patients post-discharge.

Main Methods:

• A quality improvement project using Plan-Do-Study-Act (PDSA) cycles within the geriatric patient-aligned care team (GeriPACT).
• Proactive telehealth follow-up by a Registered Nurse (RN) care manager and nurse practitioner post-home discharge.
• Utilized operational data from the Data and Statistical Services (DSS) coordinator to inform PDSA cycles.

Main Results:

• Baseline 30-day all-cause readmission rate for GeriPACT was 21% (July 2018-June 2019).
• Readmission rates decreased to 13% (July-December 2019) and 15% (January-June 2020).

Conclusions:

• Plan-Do-Study-Act (PDSA) cycles and data sharing improved 30-day all-cause readmission outcomes.
• Shared responsibility for high-risk patients within the GeriPACT team contributed to better patient outcomes.