Evaluating Intervention Allocation Policies for Reducing Hospital Readmissions at Michigan Medicine

Evaluating Intervention Allocation Policies for Reducing Hospital Readmissions at Michigan Medicine

The researchers are investigating if using a risk-based prediction score or benefit-based prediction score to allocate transition of care (TOC) interventions is more effective in reducing the rate of unplanned hospital readmissions or death within 30 days of hospital discharge.

The intervention affects only how the TOC bundle is assigned and does not alter how the telephone calls are delivered. For example, both care navigators and pharmacists receive the same patient information and follow the same call procedures before and after the intervention.

Individuals with predicted benefits greater than the 40% quantile are assigned the phone call bundle while others were not assigned the bundle. During the trial the 40% quantile will be dynamically determined using discharge data from the previous week.

Inclusion Criteria:

• Patient meets the primary care established rule at Michigan Medicine (MM), AND
• Patient's primary care physician (PCP) Department is one of our General Medicine or Family Medicine or Medical-Pediatrics departments, AND
• Inpatient class is Inpatient or Observation or Obs Greater than 48 hours or Outpatient in a Bed or Extended Recovery or Hospital Care at Home Inpatient or Hospital Care at Home Observation, AND
• Discharged from General Medicine or Family Medicine or Medicine Observation services, AND
• Disposition of home or home with home care

Exclusion Criteria:

• Physician Organization of Michigan Accountable Care Organization (POM ACO)
• Sepsis patients (had a diagnosis of sepsis during admission, active or resolved on the hospital problem list)