Impact of Implementing a Real Time Frequent Admitter Risk Score (FAM-FACE-SG) on Readmission Rates

Summary

In an earlier study using electronic health records (EHR), the investigators have identified nine factors to be significantly associated with FA risk. These nine predictors include Furosemide intravenous 40 milligrams or more; Admissions in the past one year; Medifund status; Frequent emergency department use; Anti-depressants treatment in past one year; Charlson comorbidity index; End Stage Renal Failure on dialysis; Subsidized ward stay and Geriatric patient. The investigators have combined these nine predictors into the FAM-FACE-SG score for FA risk (defined as 3 or more inpatient admissions in the following 12 months). The FAM-FACE-SG risk score has the advantage of being deployed in our hospital's enterprise data repository known as Electronic Health Intelligence System or eHINTs for short, on a real-time or near real-time basis. On a daily basis, data from multiple data sources are extracted, transformed and loaded onto the eHINTS system. The system can be programmed to run every midnight to provide risk scores the following morning for patients admitted the previous day.

In this trial, the intervention is to combine the FAM-FACE-SG risk score in addition to a decision making algorithm to guide referrals to various transitional care services based on needs assessment on nursing and function. The primary objective is to evaluate the impact of our intervention in improving healthcare utilization (hospital readmissions, emergency department (ED) attendances, length of stay up to 90 days post-discharge).

Conditions

• Patient Readmission

Interventions

OTHER

FAMFACESG

\- PNs will receive the FAM-FACE-SG FA risk scores for frequent admitters admitted to their ward.

OTHER

Control

\- Usual hospital Care

OTHER

FAMFACESG

\- PNs will be instructed to prioritize intervention of frequent admitters for intervention based on the FA risk score.

OTHER

FAMFACESG

* For high and moderate risk patients who do not require transitional home care (THC), PN will do the case management and follow up. * For high and moderate risk patients \& have complex nursing and / or high functional needs, PNs will refer these patients for THC. * For mild risk patients, PNs will refer them to care coordinator.

OTHER

FAMFACESG

\- For low risk patients, PNs will continue usual hospital care.

Sponsors & Collaborators

• Singapore General Hospital

  lead OTHER

Principal Investigators

• Lian Leng Low · Singapore General Hospital

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

21 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2016-08-31

Primary Completion

2017-08-31

Completion

2017-08-31

Countries

• Singapore

Study Locations