University Hospitals Geneva Medical Center – Predictive Analytics Program

What is it?

In January 2013, University Hospitals (UH) Geneva Medical Center launched a predictive analytics program as a means of identifying those patients at high risk for readmission and providing support through specific interventions that involve the community. All patients admitted to the hospital are scored using the LACE risk stratification tool. The risk stratification is done by using an internally validated analytics tool based on four factors: Length of stay, Acute emergent admissions, Co-morbidity index score and Emergency department visits. The LACE tool has been internally validated, and the final score is predictive of the likelihood for readmission within 30 days.

A patient with a moderate or high readmission LACE score is offered the Hospital to Home (H2H) Program, which provides home visits by an RN Case Manager. This H2H Liaison follows the patient for at least 30 days to help coordinate care and serves as a patient advocate, working with the patient to empower him/her to be the lead in the plan of care and become responsible for setting health goals. During the visit, home-going instructions are reviewed, and a nursing assessment is completed, which includes medication reconciliation and medication management. Follow-up visits with the patient’s PCP are verified and set up if needed, along with collaboration and referrals to community-based services. One-to-one education on the patient’s chronic disease and medications is also provided to the patient and his/her family.

Who is it for?

Patients at moderate to high risk for unplanned readmission within 30 days, as determined using the LACE risk stratification tool.

Why do they do it?

Unplanned readmissions are associated with a significant cost burden to the health care system, and often result in uncoordinated care. Hospital systems across the United States are looking at methods to identify and reduce their patients’ risk for readmission. This program also builds relationships with the community through the interventions developed by the multidisciplinary team, who took the time to learn and listen to gain a better understanding of the population of patients being readmitted and formulated interventions that involved community resources to meet the patient’s needs.

Impact

The LACE Program was recently replicated at each medical center within UH. This program has shown that using an internally validated predictive analytics tool can result in a decrease in high-risk, all-cause readmissions. Since implementation of the LACE program, the readmission rate decreased by 50 percent in the first year, from 15.4 percent in 2012 to 7.5 percent in 2013.

Contact: Lori Kingston, R.N.
Manager, Community Outreach
Telephone: 440-992-3639
Email: lori.kingston@uhhospitals.org