PACT with patients

Preventing readmissions for inpatients leaving the hospital was the reason for creating the Post-Acute Care Transitions program at BIDMC, but that topic rarely comes up when clinicians speak of this new program.

Rather it is the service to patients and the connections among caregivers that have been the hallmarks of the program so far. The PACT staff of eight nurses and four pharmacists is preparing to expand their services from about 30 discharges per month to 250 discharges per month.

Marc Cohen, MD, an internist at Healthcare Associates, has found PACT has helped him be "empowered to be more connected to my patients and the inpatient care team, not less." He notes that the PACT team gives patients, particularly complicated ones, a lot of one-on-one attention and, in turn, the PACT team provides him information that gives him a more detailed picture of how that patient is doing.

Cohen notes one case in particular in which the PACT team was able to advocate for a patient who needed a procedure in the shortened Thanksgiving holiday week. In addition to helping the patient get the needed appointment, a PACT nurse met with the patient while he was here.

"The patient's comment was that his care has been ‘fantastic,'" says Cohen. In another case, the PACT staff was able to obtain a patient's most up-to-date medication list in preparation for a follow-up visit, leaving more time to talk about care rather than recreating the list. The patient, family members and caregivers were all appreciative.

PACT nurses and pharmacists see inpatients while they are still at the hospital and then continue to check in, educate, problem-solve and advocate for patients for 30 days post-discharge - by phone or sometimes in person. They work in conjunction with inpatient clinicians and case management staff at the hospital and continue to connect and share information with each patient's primary care physician, specialist or other care team members.

The PACT team's goal for patients, say its nurses and pharmacists, it to help tie up the pieces of a complicated health care system and help ensure that patients truly understand and follow their post-discharge care plans. PACT Nurse Julie Cowell notes one case in which she has daily calls with the spouse of an elderly Parkinson's patient.

"In addition to talking about his symptoms and his medications, she talks to me about her thoughts and ideas, like whether he should be drinking more water," she says. "She tells me she is so happy to have someone to bounce her ideas off of."

PACT Nurse Susan Parker-Sorlien tells about one heart patient who realized he had lost his nitroglycerin medication before he went on a trip. In one of her scheduled calls to him she found out he was considering going without the medication, so at the last minute she was able to expedite getting his medicine replaced before the trip.

In another regular call, she discovered a patient on post-discharge steroids was taking one pill five times a day, which was inconvenient - she was able to confirm that he could take all five pills at once. Both were situations in which a patient may not want to "bother" a physician, but felt comfortable telling a PACT team member.

PACT Nurse Elizabeth Carlson relays a situation in which the daughter of an elderly patient wanted to make sure the physician had a certain piece of information about her parent, but she wasn't able to accompany the parent to the appointment - her sometimes forgetful brother was going with the patient that day. Carlson delivered the information directly to the physician for the appointment.

Kaitlin O'Rourke, PACT Pharmacist, says working directly with patients both in the hospital and after discharge has been a rewarding experience. She meets with each patient in the hospital at least twice to go over complicated medication regimens and to see if the patient has any questions.

"A lot comes up in these conversations - obstacles or barriers to getting or taking their medications," she says. "I have more time to sit and talk with them. The patients appreciate that - and so do the nurses on the floors."

The PACT staff started with Medicare Part A patients in Healthcare Associates with heart problems and pneumonia, but now that they are fully staffed, they plan to enroll all Medicare Part A primary care patients who are hospitalized from: Healthcare Associates; Bowdoin Street Community Health Center (where there is a strong medical home team model in place to work in conjunction with the PACT team); BID Health Care-Pastor Medical Group; BID Health Care-Washington Square; BID Health Care-Jamaica Plain; and BID Health Care-Chelsea.

The PACT program had its beginnings in an internally funded pilot that grew after BIDMC received $4.9 million from the highly competitive first round of Center for Medicare and Medicaid Innovation Grants in May 2012 to launch program designed to improve patient outcomes and prevent avoidable cost in the high-risk 30-day period following acute care hospitalization.

It is too soon to tell how PACT will impact readmission rates says Lauren Doctoroff, MD, PACT's Medical Director, but the program has resulted in a stronger voice for the patient, more and more specific information for caregivers, stronger discharge planning and more informed patients and family members.

"PACT definitely enriches the experience of the patient," she says, "and we know we are not sending patients out of the hospital without a parachute. The peace of mind for all involved is key."