263506 P.A.C.T. Program: Reducing the rate of hospital readmissions by addressing psychosocial issues

Tuesday, October 30, 2012 : 4:50 PM - 5:10 PM

Megan Key, LMSW , Department of Social Work, Mount Sinai Medical Center, New York, NY
The P.A.C.T. (Preventable Admissions Care Team) was created in the summer of 2010 in response to Medicare initiatives aimed at reducing readmission rates in hospitals nationwide. Developed at Mount Sinai Medical Center, the P.A.C.T. Program consists of four full time social workers in the transition program and two nurse practitioners and an additional social worker in the P.A.C.T. Clinic. In addition, the P.A.C.T. Program is currently piloting the use of volunteers as extenders.

The role of the social worker is to engage the patient and family at the bedside and complete a comprehensive biopsychosocial assessment to understand the unique drivers of readmissions for that patient. P.A.C.T. social workers collaborate with inpatient social workers and the medical team to enhance discharge as well as identify external programs and services to better support the patient with self-management of illnesses post-discharge. Regular phone calls to patients and home visits (if needed) are part of the intervention as is communication with next level providers.

Our goal in this presentation is to introduce the audience to the P.A.C.T. model, share lessons learned during the pilot year, as well as to provide outcome data. One year results: 83% yield; among P.A.C.T. patients who completed the five week program, there was a 37% reduction in admissions and a 53% reduction in emergency department visits. 93% of all P.A.C.T. patients had a 7-10 day follow up appointment and 90% of patients attended these appointments.

Learning Areas:
Advocacy for health and health education
Assessment of individual and community needs for health education
Chronic disease management and prevention
Implementation of health education strategies, interventions and programs
Social and behavioral sciences

Learning Objectives:
1. Describe the problem of hospital readmissions and provide a detailed description of issues specific to the Mount Sinai/East Harlem community. 2. Describe the unique, in-depth, psychosocial assessment done by PACT social workers by unpacking the richness in the 10 domains the that are addressed in the assessment. 3. List/Identify the different resources/referrals made in the community 4. Utilize 2 case examples to illustrate the creative clinical approach that the bases of the PACT pilot program. 5. Present yearly data on PACT program to reinforce the effectiveness of PACT.

Keywords: Hospitals, Social Work

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been a member of the P.A.C.T. Program since its inception in the summer of 2010 and have been instrumental in its development.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.