title: Effects of a Psychosocial Transitional Care Model on Hospitalizations and Cost of Care for High Utilizers.
abstract: 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.
authors.affiliation: a Division of General Internal Medicine , Icahn School of Medicine at Mount Sinai , New York , NY , USA.
authors.forename: Himali
authors.initials: H
authors.lastname: Weerahandi
authors.forename: Maria
authors.initials: M
authors.lastname: Basso Lipani
authors.forename: Jill
authors.initials: J
authors.lastname: Kalman
authors.forename: Eugene
authors.initials: E
authors.lastname: Sosunov
authors.forename: Claudia
authors.initials: C
authors.lastname: Colgan
authors.forename: Susan
authors.initials: S
authors.lastname: Bernstein
authors.forename: Alan J
authors.initials: AJ
authors.lastname: Moskowitz
authors.forename: Natalia
authors.initials: N
authors.lastname: Egorova
mesh_terms: D000368:Aged; D003266:Continuity of Patient Care / Q000191:economics / Q000458:organization & administration*; D005260:Female; D006760:Hospitalization / Q000191:economics / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D012189:Retrospective Studies; D012947:Social Work / Q000191:economics / Q000458:organization & administration*; D012959:Socioeconomic Factors; D000069341:Transitional Care
keywords: 30-day readmission; care coordination; high utilizers; psychosocial strain