NCT05413889 - Validation and Implementation Design of an Epic Systems 30-day Unplanned Readmission Risk Model | Crick

Overview

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

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 Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

SINGLE

Enrollment

68

Conditions

Unplanned Hospital Readmissions Patients at High Risk of Unplanned Readmission

Interventions

Epic 30-day unplanned readmission risk scoreBEHAVIORAL

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.

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

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

Locations (1)

Wake Forest University Health Sciences

Winston-Salem, North Carolina, United States

Outcomes

Primary Outcomes

Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Faith Health

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group - High Risk Readmission Program (HRI)

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Care Plus

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Population Health Pharmacy

Time frame: Day 30

Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Geriatrics Transitional Care

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

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes