Wake Forest University Health Sciences
Winston-Salem, North Carolina, 27157, United States
Completed
NCT Number: NCT05413889
Validation and Implementation Design of an Epic Systems 30-day Unplanned Readmission Risk Model
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
Completed
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Notify MeKey information
Age range
18 year and older
Sex eligibility
All sexes
Study type
Interventional
Phase
Not applicable
Primary location
About this study
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.
Who can participate
Healthy volunteers accepted: No
Only the study team can determine whether someone qualifies for participation.
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
Treatment and study plan
Epic 30-day unplanned readmission risk score
BehavioralIf 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.
Primary outcomes
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Faith Health
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Faith Health
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - High Risk Readmission Program (HRI)
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - High Risk Readmission Program (HRI)
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Care Plus
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Care Plus
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Population Health Pharmacy
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Population Health Pharmacy
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Geriatrics Transitional Care
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Geriatrics Transitional Care
-
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Mobile Health Clinic
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Control group - Mobile Health Clinic
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Faith Health
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Faith Health
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group- High Risk Readmission Program (HRI)
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - High Risk Readmission Program (HRI)
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Care Plus
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Care Plus
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Population Health Pharmacy
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Population Health Pharmacy
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Geriatrics Transitional Care
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Geriatrics Transitional Care
-
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Mobile Health Clinic
Time frame: Day 30
Number of transitional and supportive care services (TSC) referrals by providers in the Intervention group - Mobile Health Clinic
-
Provider Satisfaction Score
Time frame: Day 30
Provider satisfaction with clinical decision support tool measured by survey
Secondary outcomes
-
30 day Readmission Rate
Time frame: Day 30
proportion of index inpatient visits with an inpatient readmission within 30 days of index discharge
Sponsors and collaborators
Lead sponsor
Wake Forest University Health Sciences
Other
Registry information
Official study title
Validation and Implementation Design of a Pragmatic Randomized Controlled Trial Leveraging Epic Systems 30-day Unplanned Readmission Risk Model
Important dates
- Study start
- 2023
- Primary completion
- 2023
- Study completion
- 2023
- First posted
- Jun 10, 2022
- Registry last updated
- Dec 29, 2023
OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.
View the official ClinicalTrials.gov record (opens in a new tab)This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.