Validation and Implementation Design of an Epic Systems 30-day Unplanned Readmission Risk Model

Not Applicable

Completed

• Conditions: Patients at High Risk of Unplanned Readmission; Unplanned Hospital Readmissions
• Interventions: Behavioral: Epic 30-day unplanned readmission risk score

• Registration Number: NCT05413889
• Lead Sponsor: Wake Forest University Health Sciences

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.

Study Timeline

• Study First Submitted: 2022-06-06
• Study First Submitted QC: 2022-06-08
• Study First Posted: 2022-06-10
• Study Start: 2023-02-02
• Status Verified: 2023-05
• Primary Completion: 2023-08-15
• Study Completion: 2023-08-17
• Last Update Submitted: 2023-12-28
• Last Update Posted: 2023-12-29

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 68

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

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
intervention group (IG)	Epic 30-day unplanned readmission risk score	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

Primary Outcome Measures

Name	Time	Method
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 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	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 - 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 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 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 - 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 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
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 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 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 - Mobile Health Clinic	Day 30	Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Mobile Health Clinic
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 - Care Plus	Day 30	Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Care Plus

Secondary Outcome Measures

Name	Time	Method
30 day Readmission Rate	Day 30	proportion of index inpatient visits with an inpatient readmission within 30 days of index discharge

Trial Locations

Locations (1)

Wake Forest University Health Sciences; 🇺🇸 Winston-Salem, North Carolina, United States