Collaboration was established between case management and PACCs at onset of admission, expediting the discharge process. During each shift, PACCs assess patient mobility based on the Johns Hopkins Tool. Identification of early ambulation and clearly outlined outcome parameters decreased reliance on therapy staff and reduced SNF utilization, as PACCs identified home care appropriateness sooner in the discharge planning process.

Patients received front-loaded/every other day visits for two weeks, which reduced re-hospitalization rates and supported an acute patient’s transition to home safely. Unlike most health systems, which rely on overburdened case managers and discharge planners tasked with long lists for home health referrals and follow-up, our team of community educators and clinicians are onsite at each partner hospital to facilitate home health referrals from day one. Our unique PACC program was designed to work inside a hospital, and touches every referral going to home health from day one. Being onsite allowed us to help providers manage post acute care systems rather than having patients on a list awaiting review for one to two days.