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Outcome Measures

Primary Outcomes (15)

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

Secondary Outcomes (1)

30 day Readmission Rate
Day 30

Study Arms (2)

intervention group (IG)

EXPERIMENTAL

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

control group (CG)

NO INTERVENTION

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

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.

intervention group (IG)

Registry-reported names are shown in full. Names without a link have not yet been matched to a Syfrah profile.

Study Design

Study Type

interventional

Phase

not applicable

Allocation

RANDOMIZED

Masking

SINGLE

Who Masked

PARTICIPANT

Purpose

HEALTH SERVICES RESEARCH

Intervention Model

PARALLEL

Model Details: 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.

Sponsor Type

OTHER

Responsible Party

SPONSOR

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

Brief Summary

Registry Overview

Trial Relationships

Study Timeline

First Submitted

First Posted

Study Start

Primary Completion

Study Completion

Conditions

Outcome Measures

Primary Outcomes (15)

Secondary Outcomes (1)

Study Arms (2)

intervention group (IG)

control group (CG)

Interventions

Eligibility Criteria

You may qualify if:

Sponsors & Collaborators

Study Sites (1)

Study Officials

Enrollment

Study Design

Study Record Dates

You may not qualify if:

Data Sharing

Source record

Locations

Brief Summary

Registry Overview

Trial Relationships

Related Scientific Literature

Study Timeline

First Submitted

First Posted

Study Start

Primary Completion

Study Completion

Conditions

Outcome Measures

Primary Outcomes (15)

Secondary Outcomes (1)

Study Arms (2)

intervention group (IG)

control group (CG)

Interventions

Eligibility Criteria

You may qualify if:

Sponsors & Collaborators

Study Sites (1)

Study Officials

Enrollment

Study Design

Study Record Dates

You may not qualify if:

Data Sharing

Source record

Locations