P.A.C.T., Project Affecting Care Transitions, helps patients get the RIGHT CARE at the RIGHT PLACE at the RIGHT TIME. We provide an experienced social worker to serve as your personal patient navigator.
A patient navigator has an in-depth understanding of available community resources and will work as your partner to:
- Review patient education
- Assist with medication management
- Plan for symptom management
- Ensure proper follow up with Primary Care Provider
- Assist in making doctor appointments and arrange transportation
- Identify issues that make it difficult to receive needed medical care and work to overcome them
- Coordinate with community agencies to maximize patient benefits
- Encourage healthy diet and exercise choices
My experience with P.A.C.T. was great. The patient navigator is great and was there when I needed her. She showed me how to change my pattern of spending and was a big help. I’m doing good now and was able to not become homeless because of P.A.C.T.”
– P.A.C.T. Patient
Who is eligible:
Patients living in Knox, Laurel and Whitley counties who have a diagnosis of congestive heart failure, COPD or Pneumonia and have one or more of the following:
- High risk for readmission
- Limited family support
- Transportation needs
- Medication management needs
- Lack of necessities of life (housing, utilities, etc.)
- Two or more missed appointments with primary care provider within 6 months
- Two or more new resource referrals (home health, DME, etc.)
- Multiple prescriptions
- Frequent emergency department visits and/or hospitalizations
Referrals accepted from members of the healthcare team including, but not limited to; hospitals, physician offices, home health agencies, and nursing homes. Are you a patient, do you have a patient or family member that may be candidate for the P.A.C.T. program? Read below to learn next steps in getting them signed up for the program.
Are you a Provider/Healthcare Organization:
Download the P.A.C.T. Referral Form, fill out and fax to (606) 549-4966 OR call Carol Ball MSW, Patient Navigator, at (606) 309-5983 or email at email@example.com. Please be prepared to provide patient demographic information and reason for referral.
Over the last 2 -3 months I have referred several people to you that need help. And a personal friend who needed assistance with Assisted Living in Clinton, TN. KRHIT, didn’t care about where they lived, they just wanted to help.”
– P.A.C.T. Partner
Are you a Patient or Family Member?
Call Carol Ball, MSW, Patient Navigator, at (606) 309-5983 or email at firstname.lastname@example.org. Please be prepared to provide patient’s name, address, phone number and reason for referral.
P.A.C.T. partners with many organizations across the region to fully identify and address patient needs through it’s Community Team. A few of our regional partners include local hospitals, physician offices, long-term care facilities, health departments and home health agencies, along with several community-based organizations.
Interested in joining resources to better serve patients of Knox, Laurel and Whitley counties and improve the health of our communities? Contact, Shannon Adams, MSN, RN (606) 401-6233 or email@example.com.
We are really pleased with our first year outcomes.
- Patients Served: 100
- The patient navigator made 331 referrals to other programs to overcome barriers to care.
- 76% reduction in hospitalizations
- 51% reduction in Emergency Department visits
- 30-day readmissions for our patients is 11.5%, compared to 15.5% to 18.1% locally (source: medicare.gov).