Integrated Michigan Patient-Centered Alliance in Care Transitions (I-MPACT ) is a new kind of collaborative quality initiative working with both hospitals and provider organizations across Michigan. I-MPACT's purpose is to improve patients' care transitions from hospital to home and from skilled nursing facility to home.
In an effort to keep the patient voice at the forefront of the work, patient advisors and caregivers are incorporated in hospital/provider organization clusters and are utilized in an advisory group working with the coordinating center. The Physician Alliance participates in I-MPACT, partnering with Ascension Macomb/Oakland Hospital, Ascension St John Hospital, Ascension Providence- Southfield Campus, and Ascension Providence- Novi Campus.
Improving care of patients with congestive heart failure is one goal of participating organizations in I-MPACT. Through the program, The Physician Alliance supports practices in the following ways:
- TPA notifies primary care offices of inpatient discharges to improve transitions of care, encourage follow-up with patient, and ensure scheduling of the 7-day follow-up appointment.
- Goal is increase in 7-day follow up appointments
Primary care practices can help achieve these goals and improve patient care:
1. If you receive notification that your patient was discharged from the hospital:
- Reach out to the patient within 48-72 hours post discharge for a transition of care call.
- Schedule the 7-day follow up appointment (the date of discharge is discharge day 1).
- Closely monitor that patient to help prevent a 30-day readmission.
2. Educate the patient regarding what to do after hours (“Call Us First”) to help reduce emergency department visits.
Screen for social determinants of health, which might prevent patients from managing their condition (click here to learn about NowPow and register your practice).
- Schedule more frequent follow up visits with the patient to help them manage their chronic condition.
Check out the urgent care poster and customizable handout to share with patients.