The researchers are investigating if using a risk-based prediction score or benefit-based prediction score to allocate transition of care (TOC) interventions is more effective in reducing the rate of unplanned hospital readmissions or death within 30 days of hospital discharge.
Patient meets the primary care established rule at Michigan Medicine (MM), AND
Patient's primary care physician (PCP) Department is one of our General Medicine or Family Medicine or Medical-Pediatrics departments, AND
Inpatient class is Inpatient or Observation or Obs Greater than 48 hours or Outpatient in a Bed or Extended Recovery or Hospital Care at Home Inpatient or Hospital Care at Home Observation, AND
Discharged from General Medicine or Family Medicine or Medicine Observation services, AND
Physician Organization of Michigan Accountable Care Organization (POM ACO)
Sepsis patients (had a diagnosis of sepsis during admission, active or resolved on the hospital problem list)