Table 2.

Examples of ACT Program Response for Different Areas of Impact

Area of impact	Example of contributing factors	Impact on care transition	Examples of ACT program response
Clinical acuity	• High-acuity care • High-risk medications (e.g., anticoagulants, opioids) • Multiple comorbidities	• Conflicting discharge processes and documentation from multiple services • Complex post-discharge care needs	• Establishment of complex care plan • Reconciliation of discharge plans across services • Training of PAC care team on high-acuity wound care protocols
Patient factors	• High utilization patterns • Behavioral dementia • Limited English proficiency	• Potential unmet care needs • Difficulty understanding discharge care plans	• Coaching and/or motivational interviewing to set patient and family expectations for care transition • Standardized warm handoff to next care team, including patient preferences and concerns
Social supports/social determinants of health	• Homelessness • Limited social supports • Legal issues • Complex family dynamics	• Barriers to implementing discharge care plans • Preventable readmissions	• Connect patients to PAC services and/or community resources (e.g., food, housing, social supports) • Post-discharge follow-up (phone calls, home visits)
System-level factors	• Hospital capacity barriers • Insurance coverage barriers • PAC placement barriers	• Prolonged LOS • Failure to transition patient to most appropriate PAC setting	• Modification of care plans to address PAC care setting resources and needs • Medication adjustments to reduce cost burden • Interdisciplinary problem-solving (hospital and PAC)