Making an Impact with PACT (Post-Acute Care Transitions) – A Transitions of Care Model for Vulnerable Patients

To improve care for patients with complex needs, such as homelessness, substance use disorder, and mental illness, Santa Clara Valley Medical Center developed the Post-Acute Care Transitions (PACT) initiative, which focuses on patients who are medically stable, but who do not yet have a safe discharge plan after hospitalization. Using a multidisciplinary approach, PACT coordinates a seamless transition for patients from the hospital to the nursing home where patients can access resources related to mental health, homeless medicine, substance use, wound care, housing programs, and palliative services. Once the patient is ready for discharge from the contracted nursing home, a team-based assessment informs a care coordination plan for patient integration back into the community. Since the program’s start in 2018, hospital length of stay for non-acute patients decreased by 50% from 70 to 35 days and hospital bed capacity increased by more than 5,000 hospital bed days – the program overall resulted in potential cost avoidance of over $11M. In addition, PACT patients had a low 30-day readmission rate of only 5.5% and improved access to follow-up care.


  1. Explain the importance of a safe discharge
  2. Evaluate an innovative approach to address gaps in transitions of care
  3. Identify challenges faced by vulnerable patient populations

Date and Time

Thursday, January 16, 2019 from 11:00am-12:00pm Pacific


Click hereto register for this webinar.


Pamela Sebastian, MD
Program Manager of the PACT
Santa Clara Valley Medical Center

Dr. Pamela Sebastian is a practicing physician at Santa Clara Valley Medical Center. She is also the Program Manager of the PACT (Post-Acute Care Transitions) Program.

Huy Ngo, MD
PACT Medical Director
Santa Clara Valley Medical Center

2019 Dauner Quality Award Winner

Click here to view Santa Clara Valley Medical Center 2019 Dauner Award video and application.

Continuing Education Credit

One complimentary CE unit will be provided to dues-paying member hospitals of the Hospital Quality Institute, CHPSO Patient Safety Organization, the California Hospital Association or the regional hospital associations in CA.

HQI is an approved continuing education (CE) provider by the California Board of Registered Nursing and will provide CHPSO members an opportunity to earn CEs. Provider Number CEP16793 for 1.0 contact hour.

HQI does not currently offer ACPE approved Pharmacy CE, but the State of California will accept CE from courses which have been approved for continuing education by the Medical Board of California, the California Board of Podiatric Medicine, the California Board of Registered Nursing or the Dental Board of California towards their California continuing education requirement (Section 1732.2(b) of the California Code of Regulations). Pharmacists need to keep track of CE from these sources on their own as they are not submitted to NAPB.