BIDMC’s Post-Acute Care Transitions (PACT) program was created to help prevent hospital readmissions among elderly Medicare patients. Funded through a highly competitive $4.9 million Innovation Grant from the Center for Medicare and Medicaid Services, PACT is made up of eight nurses and four pharmacists, who first see patients while they are still in the hospital and then continue to check in, educate, problem-solve and advocate for these patients for 30 days after discharge, connecting either by phone or in-person.
PACT nurses and pharmacists work closely with inpatient clinicians and case management staff at the hospital and then continued to connect and share information with each patient’s primary care physician, specialist, and other care team members. The program has not only led to cost savings and reduced readmissions – it has created valuable relationships between patients and their caregivers, who help to tie up the pieces of a complicated health care system.
PBS Newshour visited BIDMC to learn more about how PACT is making a difference to the lives of elderly Medicare patients after they leave the hospital.