The Sierra View Medical Center reduces readmissions in recovering patients by 78%, counsels those healing from home through Post-Acute Care Transitions (PACT) program
PORTERVILLE – Sierra View Medical Center rang in the new year by celebrating the one year anniversary of their newest program, which focuses on helping patients prevent future trips to the hospital.
The Sierra View Medical Center’s (SVMC) Bridge Services created the Post-Acute Care Transitions program at the dawn of 2022 to address needs outside the traditional healthcare model, and are focused on preventing readmissions. They do this through addressing social, emotional and financial needs of their patients. The program started out slowly, defining how they would identify and manage patients. Fast forward a year later, and Bridge Service’ now sees roughly 100 patients admitted into their program each month.
For those that participate in the program, 30-day readmissions have reduced by 78%. The essence of the PACT Program involves an interdisciplinary approach to help recovering patients stay healthy at home. This team approach involves support with social, emotional and financial issues, healthcare education, readmission prevention strategies and navigation to community-based programs. The PACT Program engages patients for approximately 30-45 days to ensure they continue to improve.
“Our two most common interventions have nothing to do with medications, but with social factors that affect the wellbeing of our patients: food and electricity,” clinical pharmacist Amy Shepard said. “As both of these continue to rise in expense, it is becoming more difficult for the average household to sustain, especially when poor health forces patients, or caregivers, to work less.”
The team provides information about food distribution programs and income based programs which can reduce utility bills. Devon Barlow-Merritt, manager of Bridge Services and nurse case manager, said that many patients have limited “healthcare literacy,” and just a few minutes of discharge instructions are not enough to keep patients on the right track to a healthier and quicker recovery.
“One of our main goals is to provide supportive education to the patient and their family so that they start to make small improvements in lifestyle behaviors,” Barlow-Merritt said.
Another primary success of the program is the post-discharge medication reconciliation. The PACT program’s pharmacy technician Crystal Hurtado has been able to engage over 80% of those patients who discharge as a PACT patient. One to two days after discharge the team contacts the PACT patient to ensure they have received all their discharge medications, help resolve any insurance barriers and provide additional support if needed.
The medication reconciliation process helps patients feel more supported in their transition home, according to Hurtado. During her calls to each patient, they are also able to speak with a pharmacist or a nurse case manager, and from here a basic triage is completed to confirm that patients are following the discharge plan and are not in medical distress. Many times the team is able to provide small interventions that help prevent a return to the hospital.
Through the development of the program, they have received roughly 100 patients each month who were admitted having congestive heart failure, chronic obstructive pulmonary disease (COPD) and pneumonia. However, the team can not take in every admitted patient, as they choose those who would have the best chance at success in the program. The team evaluates every admitted patient to target those that have the best possible chance of success in the program. About 50% of the identified patients are from skilled nursing facilities, have extensive mental health issues, have no ability to communicate via telephone or are unable to participate at a level which would lead to success.
To remedy this, SVMC’s Bridge Services team created a patient engagement process and developed interventions that would address their medical and social needs as well as healthcare access issues. As patient engagement improved they started to see reductions in readmission rates for participating patients. Although approximately 60% of PACT patients complete the program, not everyone is ready to make lifestyle changes.
Some of this success also comes from navigating patients to the right community-based program. Anthem Blue Cross and Healthnet have an extended case management program, funded by the California Advancing and Innovating initiative (CalAIM). These extended case management services are for those patients who are high utilizers of acute-care services, homeless or have substance use disorders. SVCM has seen a patient who sought emergency room services 36 times in the preceding 12 months reduce their visit rate to four times in the six months following the referral to CalAIM Extended Case Management, according to the SVCM press release.
