Background: As hospital length of stay has shortened from an average of 6.5 days in 2015 to 4.5 days in 2019 (1), there is increased urgency for providers to efficiently address inpatient needs and to shift diagnostic and therapeutic management to outpatient settings. Patients are faced with increased self-care burdens, often tasked to implement complex discharge plans with little support. Effective communication of key diagnostic and therapeutic changes, ownership of pending follow up and coordination of medication changes are some of the critical steps to ensure high quality, successful care transitions (2). Care transition programs vary widely in scope and outcomes, however there is consistent evidence that successful interventions reduce readmissions by addressing multiple aspects of the care transition, supporting patients beyond the hospital and responding to individual patient’s needs (3). With this in mind, in January 2018, our institution established the Innovations in Managing Patients Across Care Transitions (IMPACT) collaborative.
Purpose: IMPACT is a group of care transition programs which proactively address the needs of our most medically and psychosocially complex patients. Each program builds trusting relationships, identifies and addresses barriers to healthcare delivery, provides patient-centered comprehensive care, and connects patients with community resources. IMPACT allows individual programs a supportive forum for reflection, problem-solving, collaboration, and innovation. When a need for additional resources is identified, there is power in its collective voice in resource requests. The IMPACT collaborative is driven by sustained partnership with our patients through transitions across the healthcare continuum.
Description: IMPACT is comprised of seven distinct teams who work with complex patient populations and share the goal of supporting patients across care transitions in an innovative, patient-centered way. These teams include the Ambulatory Care Coordination Team, Complex Discharge Team, Complex High Admission Management Program, Geriatric Home Visit Program, Heart Failure Bridge and Transition Team, Intensive Case Management Program, and Transitional Care Medicine.At monthly meetings, IMPACT coordinates on multiple facets of patient care. The group shares patient experiences both informally and through formal troubleshooting case presentations. IMPACT has successfully implemented two pilot programs to provide stable housing for some of our institution’s most complex patients. The group has developed a unique social determinants of health screening tool which is used across by programs in the collaborative. IMPACT has also served as a pilot implementation group for a novel social services referral platform. Additionally, the group has sought to define which proportion of the overall institution’s patient population we care for as a collective, in an effort to set goals, identify where resources can be shared, and how we can expand our reach to best serve our patients.
Conclusions: IMPACT is an innovative institutional collaborative which brings together like-minded health care teams with the goal of supporting patients across care transitions. As each program works to meet its goals of providing complex patients with medical care, resources, and intensive case management to specific patient populations, IMPACT offers a vehicle for sharing of challenges, best practices, areas for growth, and working towards population health-based goals.