title: The Preventable Admissions Care Team (PACT): A Social Work-Led Model of Transitional Care.
abstract: 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.
authors.affiliation: a Department of Social Work Services , The Mount Sinai Hospital , New York , New York , USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Basso Lipani
authors.affiliation: a Department of Social Work Services , The Mount Sinai Hospital , New York , New York , USA.
authors.forename: Kathleen
authors.initials: K
authors.lastname: Holster
authors.affiliation: a Department of Social Work Services , The Mount Sinai Hospital , New York , New York , USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Bussey
keywords: population health; social work; transitional care