Readmission Risk Score (RecuR Score) Pilot at The University of Maryland Charles Regional Medical Center (UM CRMC)
Trial ID: NCT05765903
Status: WITHDRAWN
Study type: INTERVENTIONAL
Phase: NA
Start date: 2024-03-31
Completion date: 2026-09
Sponsor: University of Maryland, Baltimore
Conditions: Patient Readmission; Pulmonary Disease, Chronic Obstructive; Heart Failure; Diabetes Mellitus Poor Control; Hypertension; Pneumonia
Interventions: Standard of Care; Enhanced Care
Locations: University of Maryland Charles Regional Medical Center
Countries: United States
Enrollment: 0
Age range: 18 Years - None
Sex: ALL

Summary:
This study will look to implement a plan for enhanced transitional care for patients at high risk of unplanned hospital readmission in hopes of reducing their risk for readmission in the first 30 days post discharge from an inpatient encounter. Hospital readmissions are an undesirable occurrence that can increase cost for hospitals, and can cause further negative outcomes for patients. Identifying factors that increase a patient's chances of being readmitted to the hospital, as well as developing an intervention to effectively reduce this risk, has historically been challenging.

Our new method uses a combination of common features such as diagnosis and length of hospital stay, with a novel artificial intelligence (AI) algorithm, the RecuR Score model developed by the University of Maryland Medical System, that identifies patients at the highest risk of having an unplanned hospital readmission. Participants identified as higher risk will then be enrolled into our pilot where they will be randomized to receive either the standard of care treatment or an enhanced protocol that includes additional disease education, coordination of home health services, and a focus on their readmission during existing multidisciplinary team huddles.

The main goal of this study is to reduce unplanned hospital readmission within 30 days of initial discharge, in those most at risk of being readmitted, using the aforementioned novel methods for identifying these participants and a transitional care intervention. This success of this goal will be analyzed across different readmission risk levels in the study population. Secondary goals of this study include reducing unplanned hospital readmission within 90 days, reducing 30-day post-discharge mortality, and reducing 30- and 90-day emergency department (ED) usage after an initial hospitalization.

Eligibility criteria:
Inclusion Criteria

* Patient is in Observation (and is expected to be admitted) or is admitted as an Inpatient Encounter. Consider eligible patients in any unit except Emergency Department.
* Patient has RecuR Score available 24 hours after start of data collection in EHR.
* Patient is at least 18 years of age.
* Participant is willing and able to provide informed consent for the trial.
* Participant has a RecuR Score greater than or equal to 3; OR Participant has a RecuR Score greater than or equal to 2 and length of stay greater than 10 days; OR Participant has a RecuR Score greater than or equal to 2 with admitting diagnosis of COPD, CHF, Diabetes with elevated HbA1c, Hypertension, or pneumonia; OR Participant has any RecuR Score AND current admission is a readmission where participant was not enrolled during any prior admission.

Exclusion Criteria

* Patients who were enrolled in the pilot during an earlier inpatient hospital encounter.
* Patients with encounters having length of stay less than 48 hours or greater than 30 days.
* Patients who are not expected to be discharged to "home", e.g., patients who were admitted from skilled nursing facility (SNF) and are expected to be discharged to SNF. Use Admission Source (or disposition field) as an indicator of who may not be discharged home.
* Patients with an admission diagnosis of Septicemia.
* Patients who lack capacity to sign the consent and participate in the study.
* Patients who are not fluent English.
* Patients who are already receiving home health care.
* Patients who the nursing team believes will require home health care post- hospitalization.

Post-Hoc Exclusion Criteria

• Patients who leave against medical advice.

Outcomes:
Number of overall participants with 30-day post-discharge hospital readmission; Number of moderate-high risk participants with 30-day post-discharge hospital readmission