RESUMEN
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.
RESUMEN
Evidence of care coordination programs to reduce readmissions is limited. We examined whether a social work transitional care model reduced hospital utilization and costs with a retrospective cohort study conducted from 9/3/2010-8/31/2012. Patients enrolled in the Preventable Admissions Care Team (PACT) program were matched to controls. PACT patients received follow-up from a social worker to address psychosocial strain. PACT reduced thirty-day readmission rate by 34% (p = <0.001), Sixty-day hospitalization rate by 22% (p = 0.004); ninety-day hospitalization rate by 19% (p = 0.006), and but not 180-day hospitalization rate. Inpatient costs thirty days post-index were $2.7 million for PACT patients and $3.6 million for controls.