4001 – The PACT Program: Improving Care for the Chronically Critically Ill
Roughly 7-8% of ICU discharges fall under the category of chronically, critically ill (CCI). This small population is marked by lengthy hospitalization, low survival rates, and high costs of care. As the demand for critical care continues to increase with an aging population and ICU mortality rates continue to decrease amidst advances in short-term critical care management, the problems associated with CCI are only going to get worse. Thus, it is paramount that future research investigates potential methods to better manage long term care of CCI patients to reduce medical expenditure and improve patient quality of life.
The Post Acute Care Transitions (PACT) Team at Spaulding Hospital for Continuing Care (MA) is dedicated to addressing the unique set of obstacles facing CCI patients and their families. Each patient enrolled in the program is assigned a care transitions case manager (CTCM) as well as a palliative care trained social worker (PCSW), who will follow the patient from LTAC admission until home for 30 days. The CTCM will provide medical case management interventions across the care continuum, while the PCSW will provide every patient and family with an opportunity to engage in serious illness conversations. The CTCM and PSCW collaborate with providers in the post acute care network (PACN) developed by the team to ensure that a patient’s goals of care align with his/her plan of care at every step of the continuum. The PACN includes SNFs, dialysis, and homecare providers that have expressed interest in collaborating to help this seriously ill group of patients and are capable of providing the quality care necessary to meet their complex needs and goals.
The PACT program is funded by the MA Health Policy Commission and hopes to serve 200 patients over 18 months. The aim of this program is to reduce the LTAC length of stay, readmission rates, and medical expenditure for CCI patients, in order to encourage future programs of this kind.
1. Describe the roles of the CTCM and PCSW and explain how they will address barriers to achieving health and psychosocial goals of CCI patients
2. Describe the importance and impact of post acute collaboration/communication from acute care setting until patients’ return to the community
3. Apply lessons learned from the PACT program to one’s own agency/facility