Implementation Science Workshop: A Novel Multidisciplinary Primary Care Program to Improve Care and Outcomes for Super-Utilizers

Lynch CS, Wajnberg A, Jervis R, Basso-Lipani M, Bernstein S, Colgan C, Soriano T, Federman AD, Kripalani S
Source: J Gen Intern Med
Publication Year: 2016
Patient Need Addressed: Behavioral health, Care Coordination/Management, Chronic Conditions, Homelessness/housing, Substance Use
Population Focus: Complex care, Low income
Intervention Type: Staff design and care management
Type of Literature: White


Insights Results

Overview of article

  • The Preventable Admissions Care Team (PACT) Clinic to improve care for super-utilizers at Mount Sinai Hospital (MSH) was developed to reduce 30-day hospital readmission rates
  • Patients who are referred to the PACT Clinic from subspecialty practices, primary care sites, or the Emergency Department (ED) must have 3 or more chronic illnesses, psychosocial complexity (e.g., low income, low health literacy, housing instability, substance abuse or psychiatric comorbidities), as well as one of the following utilization criteria: 1) 2 or more hospitalizations in 6 months; and 2) 3 or more ED visits in 6 months, or 2 or more ED visits in 30 days
  • The PACT Clinic serves the MSH super-utilizer population with a goal of improving quality of care and health outcomes. There are several unique aspects of the clinic that serve these goals, including multidisciplinary team-based care with the clinician/social worker unit, high level of continuity, low patient–provider ratios, open access flexibility, and intensive social support
  • Specifically, the PACT Clinic model pairs either a physician or a nurse practitioner with a social worker to follow patients together; currently six teams are active. The clinician member of the team provides primary medical services for a panel of up to 100 patients, enabling high provider continuity. These low ratios also allow for close collaboration between social workers and clinicians, as well as between the physicians and nurse practitioners, leveraging strengths of all members of the team
  • In addition, the team social worker completes the care unit with the clinician, and the patients are seen by their social worker at every scheduled clinician visit. This focus on social work allows for rapid identification and intervention of psychosocial barriers to optimal health, including counseling for mental health problems, chronic disease self-management support, behavioral activation, insurance navigation, and linkage to support services. This team structure supports a high degree of care coordination and individualization
  • Lastly, open access is another distinctive feature of the PACT Clinic. The goal is to have up to 1/3 of the doctor and nurse practitioner daily visits reserved for walk-in or urgent appointments. All new patients are scheduled for a 1-hour visit with a primary care provider and an additional hour with social work. The smaller panel load also allows clinicians to meet patients in other locations, such as the ED
  • The model is currently expanding to other sites within the Mount Sinai Health System


  • From November 2012 to October 2013, 171 patients were enrolled in the PACT Clinic. In general, PACT Clinic patients were under-represented minorities and socioeconomically disadvantaged. For example, nearly all patients had Medicare, Medicaid, or were dually enrolled. The group also had a significant burden of psychiatric illness, with depression, chronic anxiety, and schizophrenia being the most common. Substance abuse affected 14 %, and 134 (79%) had received the PACT transitions intervention. Overall, mean hospital admission and ED visit rates generally fell after enrollment

Key takeaways/implications

  • Conclusions regarding the magnitude of impact of the PACT Clinic should be interpreted with caution as the evaluation lacked a concurrent control group, thus raising the possibility that some of the program’s impact is attributable to regression to the mean. High-risk patients are often enrolled in services during periods of acute crisis, and utilization can decline regardless of intervention
  • Moreover, this study could have under-detected hospitalizations and ED visits since the authors did not have access to data from hospitals other than MSH
  • Nonetheless, the preliminary data presented suggests that this is a promising model of care and is deserving of further study