Kalman explains that 1,171-licensed-bed Mount Sinai launched the PACT program to reduce exposure to federal readmission penalties and to improve health outcomes through better transition of care. "As part of our evaluation of PACT, we wanted to ensure that the program is truly reaching those who are most likely to benefit from the intervention," Kalman says.
To do that, Mount Sinai's health evidence and policy team developed a risk prediction model for readmission within 30 days using logistic regression. "The higher the score, the higher the risk of readmission," Kalman adds.
Last summer, the predictive model was applied to patients enrolled in the PACT program to determine how many of them were at high risk for 30-day readmission. "Ninety-five percent of PACT enrollees had a risk score greater than 3, meaning that their readmission rate was between 19% and 29%," Kalman says. "If these results can be substantiated through further study, we believe this could have national implications for identifying high-risk patients in real-time."
Mount Sinai is showing early success with its model, too. The PACT program has decreased its 30-day readmission rate from 30% to 12% and its emergency department visits by 63% (over three-plus months), and it has a 90% primary care show rate at seven to 10 days postdischarge for patients enrolled in the program.
Basso Lipani says the core of the transitional program's success is the engagement of patients and families in a discussion of what is uniquely driving readmissions for them. "We've learned that patients with the highest medical utilization, at highest risk for readmission, and with the most fragmented care can be reached and their readmission risk can be reduced through our intervention," she says. "The predictive model has validated not just our method of identifying patients, but our outcomes, too."
In addition to the core PACT team, the organization also is successfully piloting the use of volunteers to serve as extenders for the social workers and NPs. Program volunteers assist patients in making follow-up appointments and retrieve medicine from the pharmacy, helping patients overcome small hurdles that otherwise can have readmission consequences.