SHM Converge Scientific Abstract ePoster Gallery-Using a Mortality Risk Predictor Model to Improve Advance Care Planning for Hospitalized Patients Through a Transitions of Care Toolkit

Using a Mortality Risk Predictor Model to Improve Advance Care Planning for Hospitalized Patients Through a Transitions of Care Toolkit

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This project used a Mortality Risk Predictor Model to identify hospitalized patients at high risk of 30-day mortality so that goals-of-care and advance care planning (ACP) discussions could happen earlier and more consistently. Once high-risk patients were flagged, they were reviewed during a daily multidisciplinary palliative care huddle. The team then contacted the primary provider and offered a transitions-of-care toolkit designed to support personalized care, ACP conversations, proper EMR documentation, and education for patients and families.<br /><br />The intervention addressed a common problem in hospital care: seriously ill patients often do not receive timely prognosis discussions, in part because clinicians are not always accurate at predicting life expectancy. This can lead to unwanted interventions near the end of life. By identifying patients early, the team aimed to improve communication, resource allocation, discharge planning, and end-of-life care.<br /><br />The model successfully identified 59 patients who benefited from the toolkit during the reported period. The workflow was sustained on the hospital medicine service, and another 42 patients were identified between July and October 2021. The project also suggested broader potential benefits, including decreased observed-to-expected hospital mortality, increased palliative care consults, more code status changes, more hospice discharges, better ACP documentation, and improved patient satisfaction at discharge, with no change in readmissions.<br /><br />Planned next steps include expanding the process to other units such as the ICU and surgical services, and creating automated alerts to notify providers when patients are at high risk.

Asset Subtitle

Aparna S. Kamath

Meta Tag

Author List Amanda Bisset, Aparna S. Kamath, Merrille Asuncion, Michael Gao, Paula McKinzie, Trig Brown, William Knechtle

Category Innovations

Concept Mortality Prediction Model

Concept High-Risk Patient

Concept Advance care planning

Concept Goals of Care Discussion

Concept 30-Day Mortality

Distinguished Non-Finalist

Presenter Organization Duke Raleigh Hospital

Presenting Author Aparna S. Kamath

Track Transitions of Care

Keywords

mortality risk predictor

30-day mortality

goals of care

advance care planning

palliative care

hospitalized patients

multidisciplinary huddle

transitions of care toolkit

EMR documentation

hospice discharge

Mortality Prediction Model

High-Risk Patient

Advance care planning

Goals of Care Discussion

30-Day Mortality