Use of Modified LACE Tool to Predict and Prevent Hospital Readmissions

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What is LACE?. Tool that scores a patient on four variables with a final score predictive of readmission within 30 days.Predictive of readmissions with patient population at Chinese hospital. Paper tool, used existing resources.Risk scores are available at discharge. All key elements of safe di
Use of Modified LACE Tool to Predict and Prevent Hospital R...

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1. ?Use of Modified LACE Tool to Predict and Prevent Hospital Readmissions? By Ronald Kreilkamp RN, MSW Nurse Manager Chinese Hospital 1 Can an index, which can quantify risk of unplanned readmission within 30 days after discharge from a hospital, be adapted for clinical use to enhance the discharge process? The nursing department at Chinese hospital looked at recent research to answer that question. Can an index, which can quantify risk of unplanned readmission within 30 days after discharge from a hospital, be adapted for clinical use to enhance the discharge process? The nursing department at Chinese hospital looked at recent research to answer that question.

2. What is LACE? Tool that scores a patient on four variables with a final score predictive of readmission within 30 days. Predictive of readmissions with patient population at Chinese hospital. Paper tool, used existing resources. Risk scores are available at discharge. All key elements of safe discharge validated with Discharge Plan Checklist. A link to a paper tool and an Excel? spreadsheet at the end 2

3. 3 Objectives Know about predictive models in relation to readmissions. Know what the LACE Tool is, and its limitations. How to use and score the Modified LACE Tool in the clinical setting reliably. How to incorporate the Modified LACE Tool within the Readmission Alert Discharge Plan. How to use the Modified LACE Tool to monitor readmissions within 30 days.

4. Background The Center for Medicare and Medicaid Services will be looking at potentially preventable readmissions, (PPRs) as an indicator of care and also will be adjusting reimbursements for PPRs.1 The Center for Medicare and Medicaid posts hospital readmission rates on the web site http://www.hospitalcompare.hhs.gov/. ?Rehospitalizations among Medicare beneficiaries are prevalent and costly.?2 4 Readmissions affect the lives of patients, their families and their caregivers. ?Rehospitalizations is a frequent, costly and sometimes life threatening event?2 Elderly patients with chronic diseases are caused undo harm by readmissions3 ?Rehospitalizations among Medicare beneficiaries are prevalent and costly.?2 The Center for Medicare and Medicaid posts hospital readmission rates on the web site http://www.hospitalcompare.hhs.gov/. The United States 30-day national rate of readmission for heart attack patients is 19.9%; heart failure patients is 24.7% and pneumonia patients is 18.3%. This data is current as of April 11, 2011.4 The Center for Medicare and Medicaid Services is looking at potentially preventable admissions, (PPRs) as an indicator of care and will be adjusting reimbursements for PPRs Readmissions affect the lives of patients, their families and their caregivers. ?Rehospitalizations is a frequent, costly and sometimes life threatening event?2 Elderly patients with chronic diseases are caused undo harm by readmissions3 ?Rehospitalizations among Medicare beneficiaries are prevalent and costly.?2 The Center for Medicare and Medicaid posts hospital readmission rates on the web site http://www.hospitalcompare.hhs.gov/. The United States 30-day national rate of readmission for heart attack patients is 19.9%; heart failure patients is 24.7% and pneumonia patients is 18.3%. This data is current as of April 11, 2011.4 The Center for Medicare and Medicaid Services is looking at potentially preventable admissions, (PPRs) as an indicator of care and will be adjusting reimbursements for PPRs

5. Background The Patient Protection and affordable care act addresses the need to ?implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge....? within the context of Section 2717. Ensuring the Quality of Care.3 Hospitals need to identify potentially preventable admissions, (PPRs) in order to control readmissions rates.4 5 The Patient Protection and affordable care act addresses the need to ?implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge?5 Hospitals need to identify potentially preventable admissions, (PPRs) in order to control readmissions rates. The Patient Protection and affordable care act addresses the need to ?implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge?5 Hospitals need to identify potentially preventable admissions, (PPRs) in order to control readmissions rates.

6. Background How can patients who are at high risk of being readmitted be identified so that further readmissions can be avoided by enhancing the discharge process? The answer to this question is through the use of predictive models to flag patients at risk for readmission 6 How can patients who are at high risk of being readmitted be identified so that further readmissions can be avoided by enhancing the discharge process? One strategy is to use a tool to identify preventable readmissions.7 The answer to this question lies in the use of predictive models that can flag patients at risk for readmission. What follows is a discussion of nine predictive models seven of which are proprietary and commercially available and two generic models. How can patients who are at high risk of being readmitted be identified so that further readmissions can be avoided by enhancing the discharge process? One strategy is to use a tool to identify preventable readmissions.7 The answer to this question lies in the use of predictive models that can flag patients at risk for readmission. What follows is a discussion of nine predictive models seven of which are proprietary and commercially available and two generic models.

7. Predictive Models The Patients at Risk of Re-admission tool (PARR) This tool is used in the United Kingdom. It uses secondary care data to predict the likelihood of readmission; patients are given a score from 0-100.5 High-impact User Management Model (HUM) developed by Dr Foster. This tool uses past hospitalization data to predict likely readmission.6 Combined Predictive Model (CPM). More robust tool than the PARR, involves data mining stratifies populations with risk banding.7 7 The Patients at Risk of Re-admission tool (PARR) is a predictive model tool is used in the United Kingdom. It uses secondary care data to predict the likelihood of readmission within one year based on a score from 0-100. The High-impact User Management Model (HUM?) is a proprietary tool which uses past hospitalization data to predict likely readmissions and was developed by Dr. Foster The Combined Predictive Model (CPM) is a tool similar to the PARR but more robust in that it involves data mining and stratifies populations with risk banding. The Patients at Risk of Re-admission tool (PARR) is a predictive model tool is used in the United Kingdom. It uses secondary care data to predict the likelihood of readmission within one year based on a score from 0-100. The High-impact User Management Model (HUM?) is a proprietary tool which uses past hospitalization data to predict likely readmissions and was developed by Dr. Foster The Combined Predictive Model (CPM) is a tool similar to the PARR but more robust in that it involves data mining and stratifies populations with risk banding.

8. Predictive Models Adjusted Clinical Groups (ACG?) Suite of morbidity-based analytical tools which draw on demographic, diagnostic, pharmacy and service utilization data from primary and secondary care.8 Developed at John Hopkins University: ACG? System identifies patients at high risk, forecasting healthcare utilization and setting equitable payment rates. The ACG? System is a "person-focused" approach which allows it to capture the multidimensional nature of an individual's health over time.9 8 The Adjusted Clinical Groups (ACG?) is a suite of morbidity-based analytical tools which draw on demographic, diagnostic, pharmacy and service utilization data from primary and secondary care.11 The ACG? System identifies patients at high risk, forecasting healthcare utilization and setting equitable payment rates. The ACG? System is a "person-focused" approach which allows it to capture the multidimensional nature of an individual's health over time.11 This tool was developed at John Hopkins University The Adjusted Clinical Groups (ACG?) is a suite of morbidity-based analytical tools which draw on demographic, diagnostic, pharmacy and service utilization data from primary and secondary care.11 The ACG? System identifies patients at high risk, forecasting healthcare utilization and setting equitable payment rates. The ACG? System is a "person-focused" approach which allows it to capture the multidimensional nature of an individual's health over time.11 This tool was developed at John Hopkins University

9. Predictive Models Potentially Preventable Readmissions? (PPR?) Solutions. Developed by Dr Norbert Goldfield, ?uses administrative data to identify hospital readmissions that may indicate problems with quality of care.?10 Commercially available from 3M? Potentially Preventable Readmission Grouping Software: Identifies potentially preventable readmissions using powerful clinical grouping logic.11 9 The Potentially Preventable Readmissions? (PPR?) Solutions tool was developed by Dr Norbert Goldfield using ?administrative data to identify hospital readmissions that may indicate problems with quality of care.?12 The (PPR?) is commercially available from 3M?; it identifies potentially preventable readmissions using powerful clinical grouping logic. The Potentially Preventable Readmissions? (PPR?) Solutions tool was developed by Dr Norbert Goldfield using ?administrative data to identify hospital readmissions that may indicate problems with quality of care.?12 The (PPR?) is commercially available from 3M?; it identifies potentially preventable readmissions using powerful clinical grouping logic.

10. Predictive Models Probability of Repeated Admission Instrument (Pra?) series of 8 survey questions12 ?Prediction of readmission using the Pra? was better than chance.?13 ?readmission of high (vs. low) Pra? patients was 6 times more likely.? Pra?s? promising predictive ability may add valuable discharge planning information.?14 Pra? was further refined into the PraPlus? ?which consist of a 17-item questionnaire (the eight questions of the Pra?, plus nine additional questions questions about medical, functional ability, living circumstances, nutrition and depression).?15 Licensing available from John Hopkins University. 10 The Probability of Repeated Admission Instrument (Pra?) is a tool which uses a series of 8 survey questions14 ?Prediction of readmission using the Pra? was better than chance.?15 ?Readmission of high (vs. low) Pra? patients was 6 times more likely.? Pra?s? promising predictive ability may add valuable discharge planning information.? The Probability of Repeated Admission Instrument (Pra?) was further refined into the PraPlus?17 ?which consist of a 17-item questionnaire (the eight questions of the Pra?, plus nine additional questions questions about medical, functional ability, living circumstances, nutrition and depression).?17 The licensing for this tool is available from John Hopkins University. The Probability of Repeated Admission Instrument (Pra?) is a tool which uses a series of 8 survey questions14 ?Prediction of readmission using the Pra? was better than chance.?15 ?Readmission of high (vs. low) Pra? patients was 6 times more likely.? Pra?s? promising predictive ability may add valuable discharge planning information.? The Probability of Repeated Admission Instrument (Pra?) was further refined into the PraPlus?17 ?which consist of a 17-item questionnaire (the eight questions of the Pra?, plus nine additional questions questions about medical, functional ability, living circumstances, nutrition and depression).?17 The licensing for this tool is available from John Hopkins University.

11. Generic Predictive Models Multicenter Hospitalist Study (MCH) done at 6 US academic medical centers. Seven patient characteristics noted to be significant predictors of unplanned hospital admission within 30 days of discharge:16 Health Insurance Status Marital Status Having a regular physician Charlson comorbidity index Short Form-12 physical component score Prior hospital admission within last 12 months Hospital length of stay longer than 2 days17 11 The Multicenter Hospitalist Study (MCH) was done at 6 US academic medical centers. Seven patient characteristics were noted to be significant predictors of unplanned hospital admission within 30 days of discharge:18 ?Health Insurance Status ?Marital Status ?Having a regular physician ?Charlson comorbidity index ?Short Form-12 physical component score ?Prior hospital admission within last 12 months ?Hospital length of stay longer than 2 days The Multicenter Hospitalist Study (MCH) was done at 6 US academic medical centers. Seven patient characteristics were noted to be significant predictors of unplanned hospital admission within 30 days of discharge:18 ?Health Insurance Status ?Marital Status ?Having a regular physician ?Charlson comorbidity index ?Short Form-12 physical component score ?Prior hospital admission within last 12 months ?Hospital length of stay longer than 2 days

12. The LACE Index. Dr Carl van Walraven et al., looked at 48 patient-level and admission level variables for 4812 patients discharged form 11 hospitals in Ontario. Four variables were independently associated with unplanned readmissions within 30 days.18 12 The LACE Index: Dr Carl van Walraven et al., looked at 48 patient-level and admission level variables for 4812 patients discharged form 11 hospitals in Ontario. The LACE index was then externally validated ?using three population-based administrative databases that capture data on all Ontarians?1 The LACE index can be used to quantify the risk of an unplanned readmission within 30 days after discharge from a hospital1 Patients are assigned a score from 0 to 19 based on these four variables to predict an unplanned admission within 30 days of discharge from a hospital. The LACE Index: Dr Carl van Walraven et al., looked at 48 patient-level and admission level variables for 4812 patients discharged form 11 hospitals in Ontario. The LACE index was then externally validated ?using three population-based administrative databases that capture data on all Ontarians?1 The LACE index can be used to quantify the risk of an unplanned readmission within 30 days after discharge from a hospital1 Patients are assigned a score from 0 to 19 based on these four variables to predict an unplanned admission within 30 days of discharge from a hospital.

13. Four variables are independently associated with unplanned readmissions within 30 days. 13 Four variables were independently associated with unplanned readmissions within 30 days.1 The mnemonic ?LACE? is used to identify those four variables: Length of stay. Acuity of the admission. Comorbidities using the Charlson comorbidity index.20 Emergency room visits in the past 6 months. Four variables were independently associated with unplanned readmissions within 30 days.1 The mnemonic ?LACE? is used to identify those four variables: Length of stay. Acuity of the admission. Comorbidities using the Charlson comorbidity index.20 Emergency room visits in the past 6 months.

14. Scoring the LACE Tool. Patients are scored on: 1. Length of stay. 2. Acuity of the admission (patients admitted as observation status are scored 0 points, if admitted as an inpatient 3 points). 3. Comorbidity is assessed by type and number of comorbidities, (comorbidity points are cumulative to maximum of 6 points). 4. Emergency room visits during the previous six months. 14 The nursing department wanted to find a suitable tool to identify the frail elderly served at Chinese Hospital who are at risk for readmission. The first seven predictive models relative to readmission as previously discussed are proprietary and involve cost. The Multicenter Hospitalist Study (MCH)18 was too time consuming for nursing staff to use. The LACE Index was chosen to identify patients at risk for readmission because of its simplicity of use and because it had been validated. The nursing department wanted to find a suitable tool to identify the frail elderly served at Chinese Hospital who are at risk for readmission. The first seven predictive models relative to readmission as previously discussed are proprietary and involve cost. The Multicenter Hospitalist Study (MCH)18 was too time consuming for nursing staff to use. The LACE Index was chosen to identify patients at risk for readmission because of its simplicity of use and because it had been validated.

15. Modified Attributes of LACE Tool. The first attribute, Length of stay, was not modified. The second attribute, Acuity of the admission, was modified so that patients admitted as inpatients are given 3 points, patients placed in observation status are give 0 points. The third attribute, the Charlson comorbidity Index, was modified to include renal disease, diabetes and peptic ulcer disease. Instructions were added on scoring the Charlson comorbidity Index.20 The fourth attribute, Emergency room visits in the past 6 months, was not modified. 15

16. LACE Tool in the Clinical Setting For ease of use the LACE Tool was modified into a table format. The LACE Tool was modified into an Excel? spreadsheet. 16 The LACE Index as developed by Dr Carl van Walraven et.al., was modified into a table format for ease of use.1 The LACE Tool was also modified into an Excel? spreadsheet; a link will be provided at the end of this presentation to download the spreadsheet The LACE Index as developed by Dr Carl van Walraven et.al., was modified into a table format for ease of use.1 The LACE Tool was also modified into an Excel? spreadsheet; a link will be provided at the end of this presentation to download the spreadsheet

17. 17 Here is the modified LACE tool in table format. The first attribute, Length of stay, was not modified. The second attribute, Acuity of the admission, was modified so that patients admitted as inpatients are given 3 points, patients placed in observation status are give 0 points. The third attribute, the Charlson comorbidity Index, was modified to include renal disease, diabetes and peptic ulcer disease. Instructions were added on scoring the Charlson comorbidity Index.23 The fourth component of LACE, Emergency room visits in the past 6 months was not modified. Here is the modified LACE tool in table format. The first attribute, Length of stay, was not modified. The second attribute, Acuity of the admission, was modified so that patients admitted as inpatients are given 3 points, patients placed in observation status are give 0 points. The third attribute, the Charlson comorbidity Index, was modified to include renal disease, diabetes and peptic ulcer disease. Instructions were added on scoring the Charlson comorbidity Index.23 The fourth component of LACE, Emergency room visits in the past 6 months was not modified.

18. Limitations The patient population used by Walraven et al18 in their study is different from the patient population at Chinese Hospital so the LACE Tool will have to be studied with the patient population at Chinese Hospital. Chinese Hospital Nursing Department did a chart review of 509 unplanned admissions from January to April 2010 using the Modified LACE Tool. 18 Dr Carl van Walraven et al., state one of the limitations of the study is: ?the index cannot be used reliably in patient populations that were not involved in its derivation.?1 The LACE Index must be studied first with the patient population at Chinese Hospital. Chinese Hospital Nursing Department used the Modified LACE Tool to score 509 unplanned admissions from January to April 2010. The next slide shows how these admissions scored graphicallyDr Carl van Walraven et al., state one of the limitations of the study is: ?the index cannot be used reliably in patient populations that were not involved in its derivation.?1 The LACE Index must be studied first with the patient population at Chinese Hospital. Chinese Hospital Nursing Department used the Modified LACE Tool to score 509 unplanned admissions from January to April 2010. The next slide shows how these admissions scored graphically

20. Results showed 95, (18.7%) of the 509 admissions were readmitted within 30 days from discharge. Of these 95 readmissions only 6, (6.3%) had a LACE score of 10 or less; however 89 of the 95 readmissions (93.7%) had LACE scores of 11 or greater. Results showed 95, (18.7%) of the 509 admissions were readmitted within 30 days from discharge. Of these 95 readmissions only 6, (6.3%) had a LACE score of 10 or less; however 89 of the 95 readmissions (93.7%) had LACE scores of 11 or greater.

21. Scoring the Modified LACE Tool Upon admission the patient?s record will be checked to see if the patient was discharged within 30 days of the present admission. In that case the previous admission will be assigned a LACE score. The present admission will be assigned a projected LACE score based on 3 days Length of Stay (LOS). 21 The LACE index is predictive of the risk of unplanned admission at Chinese Hospital. Patients scoring =11 with the LACE Index are considered to be at high risk for readmission. Each unplanned admission will be assessed using the modified LACE Index Tool. The patient?s record will be checked upon admission to see if this patient was discharged within 30 days of the present admission; if that is the case the previous admission will be assigned a LACE score. The present admission will be assigned a projected LACE score based on 3 days LOS The LACE index is predictive of the risk of unplanned admission at Chinese Hospital. Patients scoring =11 with the LACE Index are considered to be at high risk for readmission. Each unplanned admission will be assessed using the modified LACE Index Tool. The patient?s record will be checked upon admission to see if this patient was discharged within 30 days of the present admission; if that is the case the previous admission will be assigned a LACE score. The present admission will be assigned a projected LACE score based on 3 days LOS

22. How to use and score the Modified LACE Tool in the clinical setting reliably. Nurses were in serviced in group settings using case studies. Here are four case studies to score. 22 The staff nurses were given in-service on scoring the modified LACE Index tool through case studies to ensure reliability in scoring. Here are examples of four case studies given and how each case study is scored: The staff nurses were given in-service on scoring the modified LACE Index tool through case studies to ensure reliability in scoring. Here are examples of four case studies given and how each case study is scored:

23. 23 Case Study # 1 Mrs. Q presented with abdominal pain to the Emergency Room on June 9th. Mrs. Q was sent to the 3rd floor for observation of abdominal pain. Mrs. Q has a history of metastatic liver cancer and dementia. She was recently discharged on August 8th from General hospital. The previous admission she went to see her PCP on August 3rd and her PCP had her directly admitted to General hospital for pain control and dehydration. Mrs. Q has not been to an Emergency Room for 8 months.Case Study # 1 Mrs. Q presented with abdominal pain to the Emergency Room on June 9th. Mrs. Q was sent to the 3rd floor for observation of abdominal pain. Mrs. Q has a history of metastatic liver cancer and dementia. She was recently discharged on August 8th from General hospital. The previous admission she went to see her PCP on August 3rd and her PCP had her directly admitted to General hospital for pain control and dehydration. Mrs. Q has not been to an Emergency Room for 8 months.

24. 24 Scoring Case Study # 1 Mrs. Q has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Placed in Observation status = 0 points. She has a metastatic liver cancer = 6 points and dementia = 3 points, (comorbibity points are cumulative to a maximum of 6 points) total comorbidity score = 6 points. No ER visit in 6 months = 0 points. LACE score for present admission is 9 points. Scoring Case Study # 1 Mrs. Q has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Placed in Observation status = 0 points. She has a metastatic liver cancer = 6 points and dementia = 3 points, (comorbibity points are cumulative to a maximum of 6 points) total comorbidity score = 6 points. No ER visit in 6 months = 0 points. LACE score for present admission is 9 points.

25. 25 Scoring Case Study # 1 Mrs. Q has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Placed in Observation status = 0 points. She has a metastatic liver cancer = 6 points and dementia = 3 points, (comorbibity points are cumulative to a maximum of 6 points) total comorbidity score = 6 points. No ER visit in 6 months = 0 points. LACE score for present admission is 9 points. Scoring Case Study # 1 Mrs. Q has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Placed in Observation status = 0 points. She has a metastatic liver cancer = 6 points and dementia = 3 points, (comorbibity points are cumulative to a maximum of 6 points) total comorbidity score = 6 points. No ER visit in 6 months = 0 points. LACE score for present admission is 9 points.

26. 26 Case Study # 2 Mrs. W went to see her PCP on June 9th. Mrs. W was sent to General Hospital as a direct admit on June 9th for hyperglycemia and severe anemia. Mrs. W has a history of chronic renal failure. She has diabetes, which has lead to neuropathy of her lower extremities and partial blindness in her right eye. She was recently discharged on January 8th from General hospital. The previous admission she went to see her PCP on January 3rd and was directly admitted to General hospital for thrombosis of a right AV graft. She has been to the Emergency Room 10 times in the last 5 months due to hypoglycemia.Case Study # 2 Mrs. W went to see her PCP on June 9th. Mrs. W was sent to General Hospital as a direct admit on June 9th for hyperglycemia and severe anemia. Mrs. W has a history of chronic renal failure. She has diabetes, which has lead to neuropathy of her lower extremities and partial blindness in her right eye. She was recently discharged on January 8th from General hospital. The previous admission she went to see her PCP on January 3rd and was directly admitted to General hospital for thrombosis of a right AV graft. She has been to the Emergency Room 10 times in the last 5 months due to hypoglycemia.

27. 27 Scoring Case Study # 2 Mrs. W has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. She has a chronic renal failure = 2 points and diabetes with end organ damage = 2 points; total comorbidity score = 4 points. 10 ER visits in 6 months = 4 points. LACE score for present admission is 14 points.Scoring Case Study # 2 Mrs. W has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. She has a chronic renal failure = 2 points and diabetes with end organ damage = 2 points; total comorbidity score = 4 points. 10 ER visits in 6 months = 4 points. LACE score for present admission is 14 points.

28. 28 Scoring Case Study # 2 Mrs. W has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. She has a chronic renal failure = 2 points and diabetes with end organ damage = 2 points; total comorbidity score = 4 points. 10 ER visits in 6 months = 4 points. LACE score for present admission is 14 points.Scoring Case Study # 2 Mrs. W has not been discharged within 30 days of the present admission so only the present admission will be scored. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. She has a chronic renal failure = 2 points and diabetes with end organ damage = 2 points; total comorbidity score = 4 points. 10 ER visits in 6 months = 4 points. LACE score for present admission is 14 points.

29. 29 Case Study # 3 Mr. X presented with chest pain in the Emergency Room at Community hospital on June 9th. He is admitted on June 9th to the telemetry unit for chest pain. He has CHF, COPD and had a previous MI 4 years ago. He went to the emergency room at General hospital on May 24th for SOB and was admitted for pneumonia; he was discharged on May 29th. He had an emergency room visit at Community hospital on November 28th for SOB. Correction January 28th Case Study # 3 Mr. X presented with chest pain in the Emergency Room at Community hospital on June 9th. He is admitted on June 9th to the telemetry unit for chest pain. He has CHF, COPD and had a previous MI 4 years ago. He went to the emergency room at General hospital on May 24th for SOB and was admitted for pneumonia; he was discharged on May 29th. He had an emergency room visit at Community hospital on November 28th for SOB. Correction January 28th

30. 30 Scoring Case Study # 3 Mr. X has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 5 days = 4 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 13 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 2 ER visits in 6 months= 2 points. LACE score for present admission is 13 points. Scoring Case Study # 3 Mr. X has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 5 days = 4 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 13 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 2 ER visits in 6 months= 2 points. LACE score for present admission is 13 points.

31. 31 Scoring Case Study # 3 Mr. X has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 5 days = 4 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 13 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 2 ER visits in 6 months= 2 points. LACE score for present admission is 13 points. Scoring Case Study # 3 Mr. X has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 5 days = 4 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 13 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has CHF = 2 points, COPD = 2 points, and history of MI= 5 points; total comorbidity score = 5 points. 2 ER visits in 6 months= 2 points. LACE score for present admission is 13 points.

32. 32 Case Study # 4 Mr. Y presented to the Emergency Room at General hospital on June 9th and was diagnosed with a lower GI bleed. The hospitalist admitted him as inpatient on June 9th. Mr. Y has a history of PUD. He was recently discharged on May 18th from General hospital. The previous admission he went to see his PCP on May 16th with palpitations and was directly admitted to General hospital that same day for atrial fibrillation. He had an Emergency Room visit on January 2nd.Case Study # 4 Mr. Y presented to the Emergency Room at General hospital on June 9th and was diagnosed with a lower GI bleed. The hospitalist admitted him as inpatient on June 9th. Mr. Y has a history of PUD. He was recently discharged on May 18th from General hospital. The previous admission he went to see his PCP on May 16th with palpitations and was directly admitted to General hospital that same day for atrial fibrillation. He had an Emergency Room visit on January 2nd.

33. 33 Scoring Case Study # 4 Mr. Y has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 2 days = 2 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 7 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for present admission is 8 points. Scoring Case Study # 4 Mr. Y has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 2 days = 2 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 7 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for present admission is 8 points.

34. 34 Scoring Case Study # 4 Mr. Y has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 2 days = 2 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 7 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for present admission is 8 points. Scoring Case Study # 4 Mr. Y has been discharged within 30 days of the present admission so the prior admission will be scored. Scoring the prior admission: Prior admission had a LOS of 2 days = 2 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for prior admission is 7 points. Scoring the present admission: Present admissions are automatically given a projected LOS of 3 points. Inpatient admission = 3 points. He has a history of PUD = 1 point. 1 ER visit in 6 months= 1 point. LACE score for present admission is 8 points.

35. Developing a Discharge Plan Checklist Discharge from the hospital and the transition to home or another facility requires that there is a complete handoff to address key elements to ensure a safe discharge.21 35 Discharge from the hospital and the transition to home or another facility requires that there is a complete handoff to address key elements to ensure a safe discharge. Discharge from the hospital and the transition to home or another facility requires that there is a complete handoff to address key elements to ensure a safe discharge.

36. Developing a Discharge Plan Checklist The Society of Hospital Medicine assembled a panel of care transition researchers which developed a checklist of processes and elements required for an ideal discharge. 22 The Pennsylvania Patient Safety Advisory further refined this checklist which focuses on medication safety, patient education and follow-up plans.23 36 The Society of Hospital Medicine assembled a panel of care transition researchers and they developed a checklist of processes and elements required for an ideal discharge. The Pennsylvania Patient Safety Advisory25 further refined this checklist, which focuses on medication safety, patient education and follow-up plans.26 Project Boost also utilizes a ?Universal Patient Discharge Checklist.? The Society of Hospital Medicine assembled a panel of care transition researchers and they developed a checklist of processes and elements required for an ideal discharge. The Pennsylvania Patient Safety Advisory25 further refined this checklist, which focuses on medication safety, patient education and follow-up plans.26 Project Boost also utilizes a ?Universal Patient Discharge Checklist.?

37. Developing a Discharge Plan Checklist This Discharge Plan Checklist was modified for use at Chinese Hospital to validate that key elements for a safe discharge have been completed. 37 A discharge plan checklist was modified for use at Chinese Hospital to validate that key elements for a safe discharge have been completed. A discharge plan checklist was modified for use at Chinese Hospital to validate that key elements for a safe discharge have been completed.

38. 38 Here is the Discharge Plan Checklist with the key elements needed for a safe dischargeHere is the Discharge Plan Checklist with the key elements needed for a safe discharge

39. Readmission Alert Discharge Plan (RAAD Plan) The Readmission Alert Discharge Plan was developed as a two page form. The Modified LACE Tool is on the front page. The Discharge Plan Checklist is on the back page. 39 The Readmission Alert Discharge Plan, ?RAAD Plan? was developed as a two page form, by incorporating the modified LACE Index Tool, (on the front page) and a Discharge Plan Checklist, (on the back page). The Readmission Alert Discharge Plan, ?RAAD Plan? was developed as a two page form, by incorporating the modified LACE Index Tool, (on the front page) and a Discharge Plan Checklist, (on the back page).

40. 40

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42. Piloting the Readmission Alert Discharge Plan (RAAD Plan) Nursing supervisors and the nurse manager piloted this project in August 2010 and scored all unplanned admissions with the Modified Lace Tool. The staff nurses completed the Discharge Plan Checklist. 42 The nursing supervisors at Chinese Hospital are the intake for all unplanned admissions. The nursing supervisor initiates the RAAD Plan for all unplanned admissions. The patient?s record is checked upon admission to see if this patient was discharged within 30 days of the present admission; if that is the case the previous admission is assigned a LACE score. The present admission will be assigned a projected LACE score based on 3 days LOS, 4-6 days LOS and 7-13 days LOS. This information is placed in the chart and is available for the patient?s health team members. The patient?s primary nurse references the LACE score to see if the patient is at high risk for readmission and utilizes the Discharge Plan Checklist to ensure all key elements are addressed to ensure a safe discharge. The nursing supervisors at Chinese Hospital are the intake for all unplanned admissions. The nursing supervisor initiates the RAAD Plan for all unplanned admissions. The patient?s record is checked upon admission to see if this patient was discharged within 30 days of the present admission; if that is the case the previous admission is assigned a LACE score. The present admission will be assigned a projected LACE score based on 3 days LOS, 4-6 days LOS and 7-13 days LOS. This information is placed in the chart and is available for the patient?s health team members. The patient?s primary nurse references the LACE score to see if the patient is at high risk for readmission and utilizes the Discharge Plan Checklist to ensure all key elements are addressed to ensure a safe discharge.

43. Piloting the Readmission Alert Discharge Plan (RAAD Plan) The staff nurses were given in-service on scoring the Modified LACE Tool through case studies to ensure consistency in scoring. In December, 2010 staff nurses scored each admission using the Modified LACE Tool. 43 The staff nurses were given in-service on scoring the modified LACE Index tool through case studies to ensure reliability in scoring. Beginning in December 2010 staff nurses scored all unplanned admission using the Modified LACE Tool and initiated the RAAD Plan for all unplanned admissions. Buy in from staff was not an issue due to the fact that the nursing supervisors and manager had been actively involved in implementing this project. Sometime patients are placed in observation status and are later changed to inpatient status. Staff nurses questioned whether the change in status from observation to inpatient status required rescoring on the Modified LACE Tool; the answer to this was yes. This indicated staff was using critical thinking. The staff nurses were given in-service on scoring the modified LACE Index tool through case studies to ensure reliability in scoring. Beginning in December 2010 staff nurses scored all unplanned admission using the Modified LACE Tool and initiated the RAAD Plan for all unplanned admissions. Buy in from staff was not an issue due to the fact that the nursing supervisors and manager had been actively involved in implementing this project. Sometime patients are placed in observation status and are later changed to inpatient status. Staff nurses questioned whether the change in status from observation to inpatient status required rescoring on the Modified LACE Tool; the answer to this was yes. This indicated staff was using critical thinking.

44. Readmission Alert Discharge Plan (RAAD Plan) The admitting nurse initiates the RAAD Plan for all unplanned admissions by using the Modified LACE Tool and providing the LACE score which is then placed in the chart and is available for the patient?s health team members. The discharge nurse references the LACE score to see if the patient is at high risk for readmission and utilizes the Discharge Plan Checklist to ensure all key elements are addressed to ensure a safe discharge. 44 All unplanned admissions at Chinese Hospital are being assessed with the Modified LACE Tool. Patients who were readmitted within 30 days from a prior discharge are identified to health team members. LACE scores for prior admissions (if there was one) and projected LACE scores for the present admission is available to health team members to identify patients at risk for being readmitted. The Readmission Alert Discharge Plan, which addresses known care transition barriers: medication, symptom management and timely follow-up with primary physician is being used to enhance the discharge process. A nursing process to identify potentially preventable admissions was instituted using existing staff and resources. LACE scores obtained at the time of discharge provides additional awareness of the risk for readmission. All unplanned admissions at Chinese Hospital are being assessed with the Modified LACE Tool. Patients who were readmitted within 30 days from a prior discharge are identified to health team members. LACE scores for prior admissions (if there was one) and projected LACE scores for the present admission is available to health team members to identify patients at risk for being readmitted. The Readmission Alert Discharge Plan, which addresses known care transition barriers: medication, symptom management and timely follow-up with primary physician is being used to enhance the discharge process. A nursing process to identify potentially preventable admissions was instituted using existing staff and resources. LACE scores obtained at the time of discharge provides additional awareness of the risk for readmission.

45. Looking Back with Lace August 2010 The RAAD Plan provides data on whether a patient had a prior admission 30 days or less from the present admission. In the month of August 2010 there were 167 unplanned admissions, of these 167 admissions 22 of these patients had a prior admission 30 days or less from the present admission in August 2010. 20 readmits (90.9%) had a LACE score of 11 or greater. 45 There were 167 unplanned admissions in August 2010. Results showed 22 of the 167 admissions were readmissions within 30 days from a prior discharge. Two readmissions, (9.1%) had a LACE score of 10 or less; twenty readmissions, (90.9%) had a LACE score of 11 or greater. Evaluation of August 2010 admissions indicated patients with a LACE score =11 are considered to be at high risk for readmission. There were 167 unplanned admissions in August 2010. Results showed 22 of the 167 admissions were readmissions within 30 days from a prior discharge. Two readmissions, (9.1%) had a LACE score of 10 or less; twenty readmissions, (90.9%) had a LACE score of 11 or greater. Evaluation of August 2010 admissions indicated patients with a LACE score =11 are considered to be at high risk for readmission.

47. Looking Forward with Lace August 2010 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of August there were 167 unplanned admissions; of these 167 admissions 24 of these patients had a post admission 30 days or less from the present admission. 23 readmits (95.8%) had a LACE score of 10 or greater. 47 Looking Forward with Lace August 2010 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of August there were 167 unplanned admissions; of these 167 admissions 24 of these patients had a post admission 30 days or less from the present admission. 23 readmits (95.8%) had a LACE score of 10 or greater. Looking Forward with Lace August 2010 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of August there were 167 unplanned admissions; of these 167 admissions 24 of these patients had a post admission 30 days or less from the present admission. 23 readmits (95.8%) had a LACE score of 10 or greater.

50. Looking Back with Lace January 2011 The RAAD Plan provides data on whether a patient had a prior admission 30 days or less from the present admission. In the month of January 2011 there were 180 unplanned admissions, of these 180 admissions 44 of these patients had a prior admission 30 days or less from the present admission in August 2010. 40 readmits (90.9%) had a LACE score of 11 or greater. 50 Looking Back with Lace January 2011. The RAAD Plan provides data on whether a patient had a prior admission 30 days or less from the present admission. In the month of January 2011 there were 180 unplanned admissions, of these 180 admissions 44 of these patients had a prior admission 30 days or less from the present admission in August 2010. 40 readmits (90.9%) had a LACE score of 11 or greater. Looking Back with Lace January 2011. The RAAD Plan provides data on whether a patient had a prior admission 30 days or less from the present admission. In the month of January 2011 there were 180 unplanned admissions, of these 180 admissions 44 of these patients had a prior admission 30 days or less from the present admission in August 2010. 40 readmits (90.9%) had a LACE score of 11 or greater.

52. Looking Forward with Lace January 2011 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of January, 2011 there were 180 unplanned admissions; of these 180 admissions 40 of these patients had a post admission 30 days or less from the present admission 37 readmits (92.5%) had a LACE score of 11 or greater. 52 Looking Forward with LaceJanuary 2011 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of January, 2011 there were 180 unplanned admissions; of these 180 admissions 40 of these patients had a post admission 30 days or less from the present admission 37 readmits (92.5%) had a LACE score of 11 or greater. Looking Forward with LaceJanuary 2011 The RAAD Plan provides an opportunity to see whether a patient once discharged is readmitted 30 days or less after the initial admission. In the month of January, 2011 there were 180 unplanned admissions; of these 180 admissions 40 of these patients had a post admission 30 days or less from the present admission 37 readmits (92.5%) had a LACE score of 11 or greater.

55. 55 Conclusion Can an index, which can quantify risk of unplanned readmission within 30 days after discharge from a hospital, be adapted for clinical use to enhance the discharge process? The answer is yes. Can the LACE Index identify patients at risk for being readmitted at Chinese Hospital? Can this be shown reliably? Can this be tied in with an evidenced based discharge plan checklist to ensure all key elements for safe discharge have been addressed? Can the staff nurses at Chinese Hospital implement and sustain this process? Can this process be implemented in a manner that does not involve any cost? The answer is yes. Can the LACE Index identify patients at risk for being readmitted at Chinese Hospital? Can this be shown reliably? Can this be tied in with an evidenced based discharge plan checklist to ensure all key elements for safe discharge have been addressed? Can the staff nurses at Chinese Hospital implement and sustain this process? Can this process be implemented in a manner that does not involve any cost? The answer is yes.

56. 56 Conclusion This happened through the collaborative efforts of the nursing supervisors and nursing staff at Chinese Hospital. All unplanned admissions at Chinese Hospital are being assessed with the Modified LACE Tool. this happened through the collaborative efforts of the nursing supervisors and nursing staff at Chinese Hospital. Staff nurses at Chinese Hospital continue to implement and sustain this process All unplanned admissions at Chinese Hospital are being assessed with the Modified LACE Tool. No additional cost was incurred to do this project. Data from admissions in August 2010 and January 2011 indicates patients who are at risk of being readmitted are being identified reliably. this happened through the collaborative efforts of the nursing supervisors and nursing staff at Chinese Hospital. Staff nurses at Chinese Hospital continue to implement and sustain this process All unplanned admissions at Chinese Hospital are being assessed with the Modified LACE Tool. No additional cost was incurred to do this project. Data from admissions in August 2010 and January 2011 indicates patients who are at risk of being readmitted are being identified reliably.

57. 57 Conclusion Patients who were readmitted within 30 days from a prior discharge are identified to health team members. LACE scores for prior admissions, (if there was one), and projected LACE scores for the present admission are available to health team members to identify patients at risk for being readmitted. Patients who were readmitted within 30 days from a prior discharge are identified to health team members. LACE scores for prior admissions, (if there was one), and projected LACE scores for the present admission are available to health team members to identify patients at risk for being readmitted. An evidenced based discharge plan checklist is being tied to the Modified LACE Tool in the context of a Readmission Alert Discharge Plan (RAAD Plan).; Patients who were readmitted within 30 days from a prior discharge are identified to health team members. LACE scores for prior admissions, (if there was one), and projected LACE scores for the present admission are available to health team members to identify patients at risk for being readmitted. An evidenced based discharge plan checklist is being tied to the Modified LACE Tool in the context of a Readmission Alert Discharge Plan (RAAD Plan).;

58. 58 Conclusion LACE scores obtained at the time of discharge provides additional awareness of the risk for readmission. Further study of readmission data and LACE scores will be ongoing as part of the effort to control readmission rates. Future plan to look at one quarters worth of data and examine for readmission patterns. Using the Modified LACE Tool raised staff awareness as to the risk of a patient for being readmitted. Using a discharge plan checklist also helped staff to validate that key elements for a safe discharge had been completed and prompted staff to ask physicians for more timely post discharge follow-up appointments. Further study of readmission data and LACE scores will be ongoing as part of the effort to control readmission rates. Adding additional resources such as follow-up phone calls for discharged patients who are at risk of being readmitted would be beneficial. Suggested resources might include follow-up phone calls from a pharmacist for patients on multiple medications; follow-up by phone by a clinical nurse specialist for symptom management or follow-up by a social worker for patients with limited support systems. Using the Modified LACE Tool raised staff awareness as to the risk of a patient for being readmitted. Using a discharge plan checklist also helped staff to validate that key elements for a safe discharge had been completed and prompted staff to ask physicians for more timely post discharge follow-up appointments. Further study of readmission data and LACE scores will be ongoing as part of the effort to control readmission rates. Adding additional resources such as follow-up phone calls for discharged patients who are at risk of being readmitted would be beneficial. Suggested resources might include follow-up phone calls from a pharmacist for patients on multiple medications; follow-up by phone by a clinical nurse specialist for symptom management or follow-up by a social worker for patients with limited support systems.

59. 59 Final Thoughts Did this project make a difference in readmission rates at Chinese Hospital? Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan showed 509 admissions of which 95 were readmitted. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan showed 493 admissions of which 77 were readmitted. One final question, did this project make a difference in readmission rates at Chinese Hospital? Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan showed 509 admissions of which 95 were readmitted. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan showed 493 admissions of which 77 were readmitted. One final question, did this project make a difference in readmission rates at Chinese Hospital? Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan showed 509 admissions of which 95 were readmitted. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan showed 493 admissions of which 77 were readmitted.

61. 61 Final Thoughts Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 18.7%. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 15.6%. Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 18.7%. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 15.6%. Baseline data obtained from unplanned admissions from January to April 2010 prior to the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 18.7%. Data obtained from unplanned admissions from January to March 2011 five months after the initiation of the RAAD Plan gives a percentage of readmissions to admissions of 15.6%.

63. 63 Thank you Contact information: Ronald Kreilkamp RN, MSW Nurse Manager Chinese Hospital 415-677-2334 ronk@chasf.org Paper tool and Excel? spreadsheet available: www.raadplan.com

64. 64 References: 1The Official Compilation of Codes, Rules and Regulations of the State of New York. Section 86-1.37 of Title 10 Readmissions. Effective date: 7/1/10 ? 2F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H. Rehospitalizations among patients in the Medicare Fee-for-Service Program. New England Journal of Medicine, 2009; 360:1418-28. ? 3Patient Protection and Affordable Care Act. Section 3025: 290-295. ? 4Norbert I. Goldfield, M.D., Elizabeth C. McCullough, M.S., et al. Identifying potentially preventable readmissions. Health Care Financing Review. Fall 2008: 30(1):75-91 ? 5http://www.kingsfund.org.uk/current_projects/predicting_and_reducing_readmission_to_hospital/ 6http://www.drfosterintelligence.co.uk/About_Us.html? 7http:www.kingsfund.org.ukcurrent_projectspredicting_and_reducing_readmission_to_hospital/ ?

65. 65 References: ? 8http://www.networks.nhs.uk/nhs-networks/commissioning-for-long-term-conditions/resources-1/risk-profiling-and-management/Modelling%20Tools%20Report%20Draft%20V1b%20-2.pdf 9http://www.acg.jhsph.org/index.php?option=com_content&view=article&id=46&Itemid=366 ? 10Norbert I. Goldfield, M.D., Elizabeth C. McCullough, M.S., John S. Hughes, M.D., Ana M. Tang, Beth Eastman, M.S., Lisa K. Rawlins, and Richard F. Averill, MS. Identifying potentially preventable readmissions. Health Care Financing Review. Fall 2008. Volume 30. no 1. 75-91. ? 11http://solutions.3m.com/wps/portal/3M/en_US/3M_Health_Information_Systems/HIS/Products/PPR/ ? 12Gordon L Jensen, Janet M Friedmann, Christopher D Coleman, and Helen Smiciklas-Wright. Screening for hospitalization and nutritional risks among community-dwelling older persons. American Journal of Clinical Nutrition 2001;74:201?5. ? 13Novotny NL, Anderson M.A., Prediction of early readmission in medical inpatients using the probability of repeated admission (PRA) instrument. Nursing Research 2008 Nov-Dec; 57 (6): 406-15. ?

66. 66 References: 14Nancy L. Novotny, M.S, RN., Predicting Early Hospital Readmission for a Cohort of Adult Inpatients Using the Probability of Repeated Admission (PRA) Instrument. The 17th International Nursing Research Congress Focusing on Evidence-Based Practice (19-22 July 2006). 15 http://www.jhsph.edu/lipitzcenter/Pra_PraPlus/index.html ? 16OmarHasan, MBBS., M.P.H., David O. Meltzer, M.D., Ph.D., Shimon A. Shaykevich, M.S., Chaim M. Bell, M.D., Ph.D., Peter J. Kaboli, M.D., M.S., Andrew D. Auerbach, M.D., M.P.H., Tosha B.Wetterneck, M.D., M.S., Vineet M. Arora, M.D., M.A., James Zhang, Ph.D., and Jeffrey L. Schnipper, M.D., M.P.H. Hospital readmission in general medicine patients: a prediction model. Journal General Internal Medicine 25(3):211?9.? 17Omar Hasan, MBBS., M.P.H. The Role of readmission risk assessment in reducing potentially avoidable hospitalization Newsletter Prescriptions for Excellence in Healthcare. Spring 2011. 18Carl van Walraven M.D, Irfan A. Dhalla. M.D, Chaim Bell M.D, Edward Etchells M.D, Ian G. Stiell M.D, Kelly Zarnke M.D, Peter C. Austin Ph.D., Alan J. Forster M.D. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010 Apr 6; 182(6):551-7.? ?

67. 67 References: ?? 19Mary E. Charlson, Peter Pompei, Kathy L. Ales and C. Ronald MacKenzie. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. Journal of Chronic Diseases. 1987 40(5):373-383. 20Srinivasan Beddhu, Frank J Bruns, Melissa Saul, Patricia Seddon, Mark L Zeidel. A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients. The American Journal of Medicine. June 2000:108(8):609-613. 21Halasyamani L, Kripalani S, Coleman E, et al. Transition of care for hospitalized elderly patients?development of a discharge checklist for hospitalists. Journal of Hospital Medicine- 2006 Nov; 1(6):354-60. 22Suggested elements for a discharge checklist. 2008 Pennsylvania Patient Safety Authority. ? 23Care at discharge?a critical juncture for transition to posthospital care. Pennsylvania Patient Safety Advisory. 2008 Jun; 5(2):39-43.

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