PACT Program: Improving Care for the Chronically Critically Ill Caitlin T. Ryan, MPH, LICSW, CCM, ACM-SW; Susan Tracy Moore, MPH, RN, CCM, HPCN
AIM: Lower costs, decrease length of stay and reduce readmissions for a subset of Spaulding Hospital Cambridge patients by addressing the unique set of obstacles facing chronically critically ill patients and their families over an 18-month program. Chronically Critically Ill (CCI): Survive initial, acute illness but continue to need life sustaining treatment and around the clock care. Marked by low long term survival rates and high readmission rates and cost of care. CCI Inclusion Criteria: Admitted directly to SHC from BWH (MGH for comparison group) and meet at least one of the following: Chronic Hemodialysis, 8+ Night ICU stay and tracheostomy placement, 8+ Night ICU stay and prolonged mechanical ventilation The program targeted two overlooked areas in the care of CCI patients: Advance Care Planning and Transitions in Care. Each patient was assigned to a Care Transitions Nurse (CTN) who provided longitudinal case management and palliative care from admission to SHC until home for 30 days. The CTN provided transition coaching for patients and families while collaborating with post acute care providers to reduce medical errors during transitions and ensure that a patient’s goals of care align with his/her plan of care at every step of the continuum. Successful patient provider communication and shared care planning helps to avoid urgent readmissions. RESULTS: Patients who were receiving the program intervention had fewer readmissions to acute care after discharge from the program. We did not see any improvement in reduction of length of stay due to program interventions. Further research into increased palliative care interventions would be beneficial. Only 47% of intervention patients received the Serious Illness Conversation. Readmissions within 30 Days of D/C to the Community 20%
17.4% 13.5%
15% 10%
17.2%
10%
5% 0%
Intervention
Comparison
Baseline
Baseline (Comparison)
CONCLUSIONS: 7-8% of ICU discharges are defined as chronically, critically ill. This population is marked by lengthy hospitalization, high risk of mortality and high overall costs Transitions are the time of highest risk for readmission due to gaps in communication and care Face to face coordination of care improves the quality of transitions for these patients In home assessment identifies multiple risks for readmission NEXT STEPS: Partners Population Health in collaboration with Case Management at the acute care hospitals now has multiple programs designed to insure safe transitions
The PACT program is supported by an Innovation Investment Award from the Commonwealth of Massachusetts Health Policy Commission (HPC). The contents of this presentation are the sole responsibility of the authors and do not necessarily represent the views of the HPC. The presenters do not have any financial conflicts of interest to disclose.