Post Acute Care Transition (PACT) Program


The PACT program is a part of the Patient Flow program at Santa Clara Valley Medical Center (SCVMC).  Starting in 2018,  the PACT program began from a growing need to care for a challenging population - patients hospitalized for a severe medical condition but cannot be safely discharged after stabilization and often requiring skilled nursing level of care.

These patients often have extensive barriers in discharge planning and outpatient integration. They are some of the highest utilizers of our medical system and often need a multi-disciplinary effort to appropriately address their psychosocial needs, medical complexities, and care coordination. To improve care for these patients with complex needs, including homelessness, substance use disorder, and mental illness, the PACT initiative was developed to focus on patients who are medically stable, but who do not yet have a safe disposition plan after hospitalization.

Placement of these patients in lower level of care is sometimes challenging as many SNFs will not accept patients without compatible health insurance plans and/or disposition plans. Recognizing this gap in care, SCVMC contracted with a local skilled nursing facility to reserve 15 beds and a dedicated team specializing to care for these patients.

Using a multidisciplinary approach, PACT coordinates a seamless transition for patients from the hospital to nursing home where patients can access resources related to mental health, homeless medicine, substance use, wound care, housing programs, and palliative services. Once a patient is ready for discharge from the nursing home, a team-based assessment informs a care coordination plan for patient integration back into the community.

Since the program’s inception, SCVMC’s hospital length of stay for non-acute patients decreased by 50% from 70 to 35 days and hospital bed capacity increased by more than 10,000 hospital bed days - allowing for a potential additional 2,000 admissions. In addition, PACT patients have a low 30-day readmission rate of 8.0% and improved access to follow-up care.

SCVMC was the 2019 Duane Dauner Award recipient by the Health Quality Institute, the 2019 Top Honor Award winner of the California Association of Public Hospitals and Health Systems’ Quality Leaders Awards (QLAs), and recognized as a top ten program in Quality by America’s Essential Hospital’s during the 2020 Gage Awards.

Presentation, Publication & News