Patients at High Risk of Unplanned Readmission, Unplanned Hospital Readmissions
Conditions
Brief summary
The objective is to assess the implementation of a computerized clinical decision support (cCDS) tool for identifying patients at high risk of unplanned readmission who could benefit from existing care programs aimed at reducing readmissions
Detailed description
Providers from either service, which includes attending physicians, residents, hospitalists, and advanced practice providers (APPs), will be randomly allocated to an intervention group (IG) or control group (CG). The IG will consist of placing the Epic 30-day unplanned readmission risk score in the story board of providers. If a patient is identified as having a high risk of readmission defined as readmission risk \>20%, a link to transitional and supportive care services (TSC) will be appear in the story board. Providers will determine which TSC is best for the patient and may order whichever TSC is appropriate for the patient. The study team will not recommend TSCs. The risk of readmission score will be present from the time of admission for those in the IG. The CG will have the same TSC orders available to them; however, they will not have the risk of readmission score present in their workflow, as such the embedded link to TSC will also not be present.
Interventions
BEHAVIORALEpic 30-day unplanned readmission risk score
If a patient is identified as having a high risk of readmission defined as readmission risk \>20%, a link to transitional and supportive care services (TSC) will be appear in the story board.
Sponsors
Wake Forest University Health Sciences
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Subject)
Intervention model description
intervention group (IG) or control group (CG). The IG will consist of placing the Epic 30-day unplanned readmission risk score in the story board of providers. If a patient is identified as having a high risk of readmission defined as readmission risk \>20%, a link to transitional and supportive care services (TSC) will be appear in the story board. Providers will determine which TSC is best for the patient and may order whichever TSC or any is appropriate for the patient. The CG will have the same TSC orders available to them; however, they will not have the risk of readmission score present in their workflow, as such the embedded link to TSC will also not be present. Providers, in both IG and CG, will have the option to order one or multiple TSC at their discretion.
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Patients of Atrium Health Wake Forest Baptist Hospital (AHWFBH) * 18 years or older * meeting inpatient criteria * admitted to hospitalist or general medicine teaching services * Providers on the hospitalist or general medicine teaching services
Exclusion criteria
* Psychiatric diagnoses during index or subsequent admission * left Against Medical Advice (AMA) * planned readmission * died during index admission * Providers who opt out of the study
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Provider Satisfaction Score | Day 30 | Provider satisfaction with clinical decision support tool measured by survey |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Faith Health | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Faith Health |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - High Risk Readmission Program (HRI) | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - High Risk Readmission Program (HRI) |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Care Plus | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Care Plus |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Population Health Pharmacy | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Population Health Pharmacy |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Geriatrics Transitional Care | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Geriatrics Transitional Care |
| Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Mobile Health Clinic | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Mobile Health Clinic |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Faith Health | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Faith Health |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group- High Risk Readmission Program (HRI) | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - High Risk Readmission Program (HRI) |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Care Plus | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Care Plus |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Population Health Pharmacy | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Population Health Pharmacy |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Geriatrics Transitional Care | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Geriatrics Transitional Care |
| Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Mobile Health Clinic | Day 30 | Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Mobile Health Clinic |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 30 day Readmission Rate | Day 30 | proportion of index inpatient visits with an inpatient readmission within 30 days of index discharge |
Countries
United States
Outcome results
None listed