VA Geri-PACT - All Cause 30-Day Hospital Readmissions

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All panel patients are continuously monitored for location of care and health status. Patients and their families/caregivers interact with The Geri-PACT Team. Other staff including clinical psychologists and dietitians will be consulted on a case-by-case basis.

Geri-PACT will have weekly teamlet meetings to communicate and coordinate care, in addition to daily warm handoff’s and electronic messaging in attention to patient care needs. Data will be monitored from dashboards and utilizing the VA corporate data warehouse (hospitalization, home and community-based services, medication profile and prescription refill data, outpatient visits, emergency room use) to follow patient trajectories, with practice changes and interventions based on teamlet review of outcomes. Data collection will include numbers of patients over age 65 with all cause readmissions less than 30 days following discharge. Semiannual chart review of high-risk patients will be performed.