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Post-Acute Care Plan

Patient-centered care reduces 30-day readmissions at large teaching hospital.

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We are a team of eight nurses and four pharmacists working together on "The Readmission Challenge" at Beth Israel Deaconess Medical Center. Our program is called Post-Acute Care Transitions (PACT). The goal of the program is to reduce 30-day readmissions through outreach to the primary care team, outpatient services such as visiting nurse associations and social services, and collaboration with patients and family members. These efforts promote adherence to plan of care, and improve health literacy and patient satisfaction.

Teaming Up for Care

Introduction to the program is done while the patient is in the hospital, usually within a day or two of admission. Nurses review the number of missed appointments, ED visits, and hospital admissions over the past year to see a pattern or barrier the patient is challenged with. Pharmacists review medication lists and refill history to evaluate adherence.

Together, the nurse and pharmacist coordinate bedside visits to introduce the program, begin a dialogue, and gather information from the patient and/or family members to identify what they feel are their barriers to care. We work with the patient's primary care physician (PCP) and act as a liaison between the hospital and PCP for 30 days after discharge. The development of trust allows for the opportunity to talk about the patient's home situation as well as his or her understanding of what wellness means and how to help him or her reach wellness goals.

Effective Outreach

Once patients are discharged, the first contact is made within 24 to 48 hours. This transitions of care management (TCM) call is to review discharge instructions and assure they have and are taking new prescriptions. We make an appointment with the PCP within 7 to 10 days of discharge, confirm other upcoming appointments with specialists, assess whether they are experiencing any new symptoms, review danger signs, etc. If they were discharged with visiting nurse services, we contact the visiting nurse agency to notify them we are involved and exchange contact information.

Subsequently, a minimum of once-a-week outreach calls are made for 30 days to assess adherence to the discharge plan, monitor symptoms, and provide support, education and referrals to outside agencies as needed.

After 30 days, if there are no outstanding issues and the patient feels comfortable managing his or her own health, calls are ended and patients can call us or their PCP for questions/concerns.

The PACT program has led to a 7% decrease in readmission rates at Beth Israel. We are successfully supporting patients so they can learn how to manage their health journey.

Susan Parker-Sorlien and Julia Cowell work at Beth Israel Deaconess Medical Center in Boston.


Photo caption: Ilona Grigoran, PharmD, Susan Parker-Sorlien, RN, BSN, and Julia Cowell, RN, BSN, MSN, HNBC-BC, consult on a patient's post-discharge care plan.


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