The objective is to assess the implementation of a computerized clinical decision support (cCDS) tool for identifying patients at high risk of unplanned readmission who could benefit from existing care programs aimed at reducing readmissions

Providers from either service, which includes attending physicians, residents, hospitalists, and advanced practice providers (APPs), will be randomly allocated to an 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 is appropriate for the patient. The study team will not recommend TSCs. The risk of readmission score will be present from the time of admission for those in the IG. 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.

Inclusion Criteria:

• Patients of Atrium Health Wake Forest Baptist Hospital (AHWFBH)
• 18 years or older
• meeting inpatient criteria
• admitted to hospitalist or general medicine teaching services
• Providers on the hospitalist or general medicine teaching services

Exclusion Criteria:

• Psychiatric diagnoses during index or subsequent admission
• left Against Medical Advice (AMA)
• planned readmission
• died during index admission
• Providers who opt out of the study

Study protocol Statistical Analysis Plan (SAP) Clinical Study Report (CSR)

Data will be available beginning 3 months and ending 5 years following article publication

Investigators whose proposed use of the data has been approved by an independent review committee ("learned intermediary") identified for this purpose