Beth Israel Deaconess Medical Center Wins $4.9 Million Grant for Program to Improve Patient Outcomes Within 30-Day Window of Discharge

One of only 26 national Center for Medicare and Medicaid Innovations Grants

Beth Israel Deaconess Medical Center will receive $4.9 million from the highly competitive first round of Center for Medicare and Medicaid Innovation Grants, to launch a Post-Acute Care Transitions (PACT) program designed to improve patient outcomes and prevent avoidable cost in the high-risk 30-day period following acute care hospitalization.

PACT will prospectively enroll all Medicare patients hospitalized at BIDMC through referrals from any one of six affiliated primary care practice sites that collectively account for approximately 30 percent of BIDMC Medicare readmissions.

The program will deploy nurse care transition specialist care coordinators and dedicated clinical pharmacists dually-sited between the hospital and primary care practice to reliably deliver a "bundle" of post-acute care interventions designed to address observed readmission risk.

"Avoidable 30-day readmissions represent a costly consequence of a fragmented care system that often falls short on the promise of better health for patients following acute care hospitalization," said BIDMC Senior Vice President of Health Care Quality Ken Sands, MD.

"Both published and organizational experience fails to identify "point" solutions that have proven effective in reducing readmissions across a generalized patient population. PACT is based in a model refined through an ongoing pilot intervention, and this grant will enable us to demonstrate the efficacy of such a program," he said.

The grant represents the first milestone for the newly announced Center for Healthcare Delivery Science, whose mission is to lead the medical center's efforts in applying rigorous, high-quality science to the evaluation of real-world innovations aimed at improving the quality, safety and value of health care.

Readmission rates can be driven by four basic factors, said Julius Yang, MD, Medical Director of Inpatient Quality at BIDMC who is leading the effort. They include a lack of continuity of post-acute care across the medical system; a widespread variation in disease-specific management following acute hospitalization; highly complex discharge medication regimens; and limited patient ability to advocate for needed medical attention in the high risk period following hospitalization.

"This innovative staffing model, utilizing personnel 'shared' between hospital and primary care practice, enables health care professionals to integrate into existing operational workflow in both sites, and to develop specialized healthcare worker expertise targeting patients' cross-continuum needs specific to the high-risk post-hospital recovery period."

The PACT program is initiated during hospitalization, continued after discharge via telephone and practice-based support, and addresses all potential transitions of care, including those involving home health agency providers and extended care facilities, in order to mitigate any identified risk factors that may contribute to avoidable readmission.

The program is anticipated to reduce the number of 30-day re-hospitalizations by 30 percent over three years, generating an estimated savings to Medicare exceeding $12 million during that time period.

BIDMC is the only Boston academic medical center to receive an Innovation grant. The Joslin Diabetes Center and the New England Asthma Regional Council were also recognized in the competitive grant process that generated approximately 3,000 applications.

"We can't wait to support innovative projects that will save money and make our health care system stronger," said Health and Human Services Secretary Kathleen Sebelius in announcing the 26 grants, funded by the Affordable Care Act, and designed to reduce health spending by $254 million over the next three years.

The projects include collaborations of leading hospitals, doctors, nurses, pharmacists, technology innovators, community-based organizations, and patients' advocacy groups, among others, located in urban and rural areas that will begin work this year to address health care issues in local communities.

For more information on the first round of awards go to:

To learn more about other innovative models being tested by the CMS Innovation Center, please visit:

Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide. BIDMC is clinically affiliated with the Joslin Diabetes Center and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit