Geisinger, Penn State Researchers Predict Risk Of Rehospitalization Within Three Days Of Discharge

In recent times, healthcare organizations have focused deeply on the causes of patient readmissions to the hospital. It’s a problem that affects both physicians and health systems, particularly if the two are not in synch.

To date, providers have focused on readmissions happening within 30 days, largely in an effort to avoid financial penalties imposed by Medicare and Medicaid. However, if the following research is solid, it could push the focus of care much closer to hospital discharge dates.

In an effort which could change the process of avoiding readmissions, a group of researchers has found a way to predict a patient’s risk for needing additional medical care within three days of discharge. The new approach developed jointly by Penn State and Geisinger Health Plan, relies on clinical, administrative and socio-economic data drawn from patients admitted to Geisinger over two years.

The model they created is known as REDD, an acronym which stands for readmission, emergency department or death. Using this model can help physicians target interventions effective and reduce the number of adverse events, according to Deepak Agrawal, one of the Penn State researchers.

You won’t be surprised to hear that readmissions after 30 days are often related to social determinants of health, such as a poor home environment, limited access to services and scant social support. Providers are certainly working to close these gaps, but to date, this has remained a major challenge.

However, the dynamics are different when finding patients who may be readmitted quickly. “Readmissions closer to discharge are more likely to related to factors that are actually present but are not identified at the time the patient is discharged,” said research team leader Sundar Kumara, Allen E. Pearce and Allen M. Pierce Professor of Industrial Engineering with Penn State, who was quoted in a prepared statement.

Another Penn State researcher, Cheng-Bang Chen, added another interesting observation. He noted that the more time that passes after a patient gets discharged, the less likely it is that problems will be caught in time. After all, it may be a while before treating physicians have time to review lengthy hospital records, and the patient could experience a time-sensitive event before the physician completes the review.

To test the REDD program, Geisinger ran a six-month pilot tracking high-risk patients and adding additional services designed to avoid readmissions, ED visits or death.

To treat this population effectively, physicians took a number of steps, such as scheduling appointments with patients’ primary care doctors, educating patients about their medications and post-discharge care plans,  having the inpatient clinical pharmacist review the provider’s recommendations, filling patient prescriptions before discharge and having the hospital check on patients discharged to a skilled nursing facility one day after discharge.

It’s worth noting that there was one major issue which undermined the research results. Penn State reported that because of a shortage of nurses at the hospital during the pilot, they couldn’t tell whether the REDD program met its goals.

Still, researchers are convinced they’re heading in the right direction. “If the REDD model was fully implemented and aligned with clinical workflows, it has the potential to dramatically reduce hospital readmissions,” said Eric Reich, manager of health care re-engineering at Geisinger.

Let’s hope he’s right.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.