TABLE 1

Institution of PACT Bundle

Measure (and Type)DescriptionTime-Bound Goal (Denominator for Rates Is Entire Enrolled Patient Population at Each Site)
Predischarge caregiver teach-back of home management skills (P)Must document successful teach-back of all 4 components:Improve documentation of successful caregiver explanation of all elements to 90% within 12 mo
 medication use
 follow-up appointments
 contingency plan (when to call PCP or return to emergency department)
 equipment contact information (if applicable)
Transition readiness checklist (P)Checklist use in paper or electronic chartImprove to 90% complete checklist use within 12 mo
 Any use: at least 1 item documented
 Complete: all items documented
Timely and complete handoff to the PCP (P)Must include documentation of all 7 elements of essential discharge communication content bundle: (admission/discharge dates, discharge diagnosis, medications, follow-up, results pending, immunizations administered during hospitalization, brief description of hospital course) and be sent within one day of dischargeImprove rates of documented discharge summaries including all 7 elements sent within one day to 90% within 12 mo
Postdischarge phone call to caregiver within 3 d of discharge (P)Transcript of call in medical record used to measure successful contactImprove contact rate (from all enrolled patients) to 70% within 12 mo
Postdischarge caregiver teach-back of home management skills (O)Caregiver demonstration of successful teach-back of all 4 components:Improve documentation of successful caregiver explanation to 90% within 12 mo (denominator is all patients with successful phone contact)
 medication use
 follow-up appointments
 contingency plan (when to call PCP or return to emergency department)
 equipment contact information (if applicable)
Reuse (O)Return to emergency department within 3 d or readmission within 30 d of index discharge dateReduce by 10% from baseline within 24 mo
  • O, outcome; P, process.