Patient PACT Lowers Readmission Rates at Boston Hospital

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)
Patient PACT Lowers Readmission Rates

In 2012, Boston’s Beth Israel Deaconess Medical Center (BIDMC) racked up more than $1 million in federal fines for its high readmissions rates. The hospital did not specify the exact rate, but Dr. Julius Yang, head of quality, recently told Kaiser Health News that patients were returning at “an alarmingly high rate.”

Readmissions are, at best, a thorny knot to untangle. Multiple causes mean any solution must be multi-pronged, addressing discharge policies, follow-up programs, and post-acute care transitions – an area where home health agencies can help.

In May 2012, BIDMC received a $4.9 million grant from CMS to launch Post-Acute Care Transitions (PACT), which is designed to help improve patient outcomes and prevent avoidable cost in the 30-day period following acute care hospitalization. It will not surprise home health executives that home care agencies are an important component of the program.

The program is expected to reduce the number of 30-day rehospitalizations by 30% over three years, saving Medicare around $12 million. It includes nurse care-transition specialists and clinical pharmacists charged with delivering a bundle of post-acute care interventions. Yang says these workers, dually situated between the hospital and primary care practices, are able to address all potential care transitions, including those to extended care and home care.

The program includes:

  • At least two in-hospital visits by a PACT specialist before discharge
  • Frequent follow up to educate, problem solve and advocate for patients for 30 days following discharge (by phone and sometimes in person)
  • Care coordination between inpatient clinicians, hospital case-management staff, the patient’s PCP, specialists and other care team members
  • Fielding questions from patients they would be unlikely to “bother” their doctor with

So far, the hospital has reduced its readmission rate by 25%, with a corresponding reduction in fines. Nurse specialists say barriers to getting and taking medications are a frequent area of focus. In addition to reducing readmission rates, Dr. Lauren Doctoroff, PACT’s medical director, says the program has strengthened discharge planning, given patients a stronger voice, and garnered more specific information for caregivers.

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