Background: Hospitals across the country employ a readmission risk assessment tool such as the LACE score (L- length of stay, A–acuity, C- Comorbidity, E- Emergency department use) to pinpoint patients at heightened risk of potentially avoidable readmissions. However, at our institution, the LACE score proved inadequate in identifying individuals with mid to late-stage chronic illnesses undergoing significant physical decline. Through collaboration with our organization’s clinical transformation team and advanced illness committee, we introduced a novel Advanced Illness Model (AIM) score designed to accurately gauge a patient’s level of frailty (figure 1). This AIM score proved effective in identifying patients who would benefit from in-depth goals of care (GOC) discussions. Research indicates that early and targeted GOC conversations promote effective transitions of care, earlier involvement of palliative care and a reduction in readmissions to the hospital.
Methods: We present an innovative approach utilizing our established digital interdisciplinary rounding tool (NORA) to encourage hospitalists to facilitate high quality GOC conversations. The project aimed to achieve two key objectives:1) promptly identify patients with high frailty index or AIM scores through a designated AIM flag integrated into NORA. We subsequently tracked the percentage of visits with GOC notes for patients above the age of 65 and/or with a high AIM score. Our additional aim was to 2) assess the readmission rate and percentage of discharges to hospice for patient visits with GOC discussions.
Results: Our study was conducted at a large tertiary academic medical center and included adults with high AIM scores between January 2022 to November 2023. To identify patients with elevated AIM, we leveraged the use of NORA, which flagged patients who met criteria with an easily identifiable pink bubble (figure 2). Once these patients were identified, hospitalists were encouraged to engage in GOC conversations which were documented in a structured and easily accessible note with emphasis on advanced care directives, code status and use of interventions aligned to a patient’s values and beliefs. For patients with life expectancies of six months or less, a hospice evaluation was considered. Prior to the integration of the NORA AIM flag, the percentage of documented GOC notes for advanced illness patients ranged from 15-17%. Post-implementation, this figure rose to 25-28%. Notably, there was a decrease in 30-day readmission rates for patients with a GOC note (15%) compared to advanced illness patients lacking a GOC note (20%). Additionally, there was a substantial increase in the percentage of discharges to hospice (6.1%) within the AIM-GOC group as opposed to discharges to hospice for patients without a GOC note (0.12%)
Conclusions: The incorporation of the AIM model into NORA has streamlined the identification and promotion of goal-directed care for patients facing advanced illness. Since the tool’s implementation in July 2023, there has been a notable uptick in GOC documentation compared to the preceding year. Furthermore, there has been a decrease in CMS 30-day readmission rates and an increase in discharges to home hospice for patients engaging in GOC conversations compared to those who did not have such discussions. The ongoing focus on reducing readmissions rates remains crucial for hospitals participating in Medicare Value Based Plans, and initiatives such as this will be instrumental in providing high quality, patient focused care.
