SHM Converge Scientific Abstract ePoster Gallery-Risky Business: Evaluating an Internal Readmission Risk Tool

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This document summarizes an evaluation of the University of New Mexico Hospital (UNMH) readmission risk assessment tool. Because hospital readmissions are common, costly, and associated with poorer outcomes, the authors examined how well the internal tool identifies patients at risk for 30-day readmission and how it is used in practice.<br /><br />The study used interviews and a Gemba walk to create a process map of current tool use. Readmission data from Vizient were reviewed for 19,882 unique admissions from January to June 2021. Encounters were categorized by the tool’s readmission risk score: low, moderate, or high, and these scores were compared with actual 30-day readmissions. The team also assessed how often tool subfields were completed.<br /><br />The tool was completed for 19,028 of the 19,882 admissions. Readmission rates increased with risk category, but performance was limited: high-risk patients had a 17.5% readmission rate, moderate-risk patients 13%, and low-risk patients 9.6%. Among readmitted patients, the most commonly completed subfields were two or more chronic conditions, lack of an advanced directive, and anticipated length of stay of three days.<br /><br />The process map showed that nurse case managers complete the tool within 24 hours of admission, mainly through chart review, and then use it to guide discharge planning and follow-up. High-risk patients may receive post-discharge calls and care coordination.<br /><br />The authors identified several opportunities for improvement: complete the tool closer to discharge, involve patients and families more directly, address high-risk issues during hospitalization rather than after discharge, and improve completion of skipped variables. They also suggest updating the tool with additional validated predictors and comparing it with external readmission risk calculators.

Asset Subtitle

Julia Howard

Meta Tag

Author List Anthony Worsham, Avanika Mahajan, Christopher S. Bartlett, Eva Angeli, Julia Howard, Krystle D. Apodaca

Category Research

Concept Readmission Risk Assessment

Concept Hospital Readmission

Concept Risk Stratification

Concept Risk Category

Concept Variable

Distinguished Non-Finalist

Presenter Organization University of New Mexico School of Medicine

Presenting Author Julia Howard

Track Quality Improvement

Keywords

University of New Mexico Hospital

readmission risk assessment

30-day readmission

hospital readmissions

Vizient data

risk stratification

nurse case managers

discharge planning

process map

predictive tool evaluation

Readmission Risk Assessment

Hospital Readmission

Risk Stratification

Risk Category

Variable