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

Study Overview
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Brief Summary
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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
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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.

Official Title
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Validation and Implementation Design of a Pragmatic Randomized Controlled Trial Leveraging Epic Systems 30-day Unplanned Readmission Risk Model

Conditions
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Unplanned Hospital Readmissions, Patients at High Risk of Unplanned Readmission

Intervention / Treatment
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* Behavioral: Epic 30-day unplanned readmission risk score


Participation Criteria
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Eligibility Criteria
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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

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional 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.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: intervention group (IG)<br>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 | Behavioral: Epic 30-day unplanned readmission risk score<br>* 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.<br>|
| No Intervention: control group (CG)<br>The CG will have the same transitional and supportive care services (TSC) orders available to them; however, they will not have the risk of readmission score present in their workflow | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 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 Intervention 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 | 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 - Faith Health | 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 - High Risk Readmission Program (HRI) | 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 - Care Plus | 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 - Population Health Pharmacy | 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 - Geriatrics Transitional Care | 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 Control group - Mobile Health Clinic | 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 - Faith Health | 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 - High Risk Readmission Program (HRI) | 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 - Care Plus | 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 - Population Health Pharmacy | 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 - Geriatrics Transitional Care | 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 Intervention group - Mobile Health Clinic | Day 30 | 
| Provider Satisfaction Score | Provider satisfaction with clinical decision support tool measured by survey | Day 30 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 30 day Readmission Rate | proportion of index inpatient visits with an inpatient readmission within 30 days of index discharge | Day 30 |