Improving Care Transitions Through Risk Reduction with Machine Learning Support

Problem: The ambulatory care management team at Carilion Clinic lacked the necessary tools to demonstrate readmission risk reduction for patients undergoing care transitions. Purpose: This quality improvement project aimed to determine if implementing a real-time workflow management system which supported the prioritization, intervention tracking, and coordination of transitions of care, would result in readmission avoidance through risk reduction. Background: The Accountable Care Strategies team implemented an electronic Transition Tracking Tool (T3), as one aspect of Carilions readmission reduction program. Evidence from the literature: Approximately 20% of Medicare beneficiaries are readmitted within 30 days following hospital or facility-based care (Fischer et al., 2014). Many health systems across the country have developed strategies to reduce hospital readmissions after the passage of the Patient Protection and Affordable Care Act and its requirement for the implementation of a Hospital Readmissions Reduction Program (ACA, 2010). While there are a variety of readmission risk stratification tools used to identify patients, the predictive performance of these tools, according to Kansagara et al., (2011), has been marginal due in part to the complex factors contributing to a readmission. These researchers recommend incorporating a larger data set to include social determinants of health (Kansagara et al., 2011). Patients social determinants have a significant impact on their readmission risk, thus ambulatory programs which address these factors are essential (Calvillo-King et al., 2013). EBP Question: (1) Is there an impact on readmission for a patient who undergoes risk reduction strategies by a nurse using an automated patient prioritization tool with predictive interventions? Methods: The ambulatory care management team uses a relationship-based model, partnering with patients in self-care which is grounded in Dorothea Orems Theory of Self-Care (Petiprin, 2016). The aim is to support personal agency in ...