UM CRMC RecuR Score Pilot

Summary

This study will look to implement a plan for enhanced transitional care for patients at high risk of unplanned hospital readmission in hopes of reducing their risk for readmission in the first 30 days post discharge from an inpatient encounter. Hospital readmissions are an undesirable occurrence that can increase cost for hospitals, and can cause further negative outcomes for patients. Identifying factors that increase a patient's chances of being readmitted to the hospital, as well as developing an intervention to effectively reduce this risk, has historically been challenging.

Our new method uses a combination of common features such as diagnosis and length of hospital stay, with a novel artificial intelligence (AI) algorithm, the RecuR Score model developed by the University of Maryland Medical System, that identifies patients at the highest risk of having an unplanned hospital readmission. Participants identified as higher risk will then be enrolled into our pilot where they will be randomized to receive either the standard of care treatment or an enhanced protocol that includes additional disease education, coordination of home health services, and a focus on their readmission during existing multidisciplinary team huddles.

The main goal of this study is to reduce unplanned hospital readmission within 30 days of initial discharge, in those most at risk of being readmitted, using the aforementioned novel methods for identifying these participants and a transitional care intervention. This success of this goal will be analyzed across different readmission risk levels in the study population. Secondary goals of this study include reducing unplanned hospital readmission within 90 days, reducing 30-day post-discharge mortality, and reducing 30- and 90-day emergency department (ED) usage after an initial hospitalization.

Conditions

• Patient Readmission
• Pulmonary Disease, Chronic Obstructive
• Heart Failure
• Diabetes Mellitus Poor Control
• Hypertension
• Pneumonia

Interventions

OTHER

Standard of Care

* Diagnosis education. * Follow-appointment scheduling assistance. * Offer resources in the community. * Offer weekly follow-up calls for one month. * Social Determinants of Health (SDoH) assessment.

OTHER

Enhanced Care

* Additional educational training using computer tablet devices, such as iPads. * Focus on readmission risk. * Set-up Home Health Services (HHS), Mobile Integrated Healthcare (MIH) or Resources, Education and Access to Community Health (REACH).

Sponsors & Collaborators

• University of Maryland, Baltimore

  lead OTHER

Principal Investigators

• Stephen N Davis, MBBS · University of Maryland, Baltimore

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

NONE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2024-03-31

Primary Completion

2026-09-30

Completion

2026-09-30

Countries

• United States

Study Locations