Hospital Readmissions Risk Prediction and Prevention (HARPP)


Overview

The HARPP model utilizes electronic health record (EHR) data combined with data used to compute the LACE score to predict risk of readmission and the likelihood of a patient benefiting from a post discharge intervention.


Value Proposition to Michigan Medicine

An unplanned readmission is a hospital readmission that occurs within 30 days of the initial admission. Reducing readmissions yields significant benefits for a hospital system. Initiatives such as the Blue Cross Blue Shield Pay-for-Performance program, the Center for Medicare & Medicaid (CMS)’s Hospital Readmission Reduction Program (HRRP), or value-based contracts hinge on the performance of this metric. High readmission rate reflects low patient care quality​.

  • Frequent readmission leads to overall higher healthcare costs​

  • Hospitals are financially incentivized to reduce hospital readmission rate​

  • Performance on readmissions is included in every value-based contract in which Michigan Medicine participates​

  • Meets strategic BASE goals at Michigan Medicine

  • These results will be immediately implemented in practice. Whichever model turns out to have the best performance will be used operationally at Michigan Medicine to support the Central TOC team’s goal to reduce readmissions.

Principal Investigator(s)

Michael Sjoding, MD, MSc

Jenna Wiens, PhD

Clinical Champion

Hae Mi Choe, PHARMD

Digital Health Innovation Support

Digital Health Innovation is supporting a 3-month randomized control trial (RCT), where post-discharge phone calls will be performed based on an EHR developed lottery tool rather than the LACE score. The RCT will enable us to compare results from LACE, Epic Readmissions Model, and HARPP. We will evaluate data-driven approaches to target post-discharge interventions at Michigan Medicine to reduce readmissions as well as:

  • Develop an EHR-based lottery design tool in MiChart

  • Explore benefit-over risk-based approach for guiding interventions

  • Explore utility of hospital-developed (custom) vs. hospital-fine-tuned (Epic) vs. generic risk scores​ (LACE)

Partnerships

College of Engineering 

Clinical Intelligence Committee (CIC)

Health Information Technology and Services (HITS)

MM Central TOC team

Intellectual Property

Invention Disclosure #

Patent Issued: