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

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.