Abstract
Transition from a skilled nursing facility or rehabilitation center to the community can be fragmented and insufficiently case managed, resulting in inadequate care recommendations, patient-caregiver distress, a delay in discharge, and a higher risk of nursing home readmission. The Providing Assistance to Caregivers in Transition (PACT) program is an interdisciplinary case management program designed to enhance nursing home discharge planning and case management support for the transitional period following a return to the community. During the PACT program's initial 24 months of operation, 38 of 42 opened cases were assisted in a discharge to the community. Of these, 30 remained at home for at least 6 months, 5 were readmitted within 6 months, and 3 others died. Caregivers reported satisfaction with instrumental (e.g., information about care options, facilitation of referrals to services) and emotional support. Nursing home cooperation was mixed. More work is needed to develop a broader referral base for the program.
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