The Preventable Admissions Care Team (PACT): A social work–led model of transitional care
Lipani, M. B., Holster, K., & Bussey, S. (2015). The Preventable Admissions Care Team (PACT): A social work–led model of transitional care. Social Work in Health Care, 54(9), 810–827.
The Preventable Admissions Care Team (PACT), a social work–led transitional care model, was developed at Mount Sinai to reduce 30-day readmissions among high-risk patients. PACT begins with a comprehensive bedside assessment to identify the psychosocial drivers of readmission. In partnership with the patient and family, a patient-centered action plan is developed and carried out through phone calls, accompaniments, navigations, and home visits, as needed, in the first 30 days following discharge.
