CareCentra and Intermountain Healthcare Collaborate on Patient Readmission Risk Score Platform

Heart failure and acute myocardial infraction are leading causes of hospitalization, especially for adults older than 65 years of age. One in every three deaths in the United States is attributed to heart disease, and preventing hospital readmission among these patients is not only a key quality measure, but also a major goal outlined in the Affordable Care Act. 

Until now, it has been challenging to develop and use accurate predictive risk stratification models because of the added time, research involved and complexity to gather the data and compute a risk score. Intermountain's readmission risk score for heart failure and acute myocardial infraction patients solves this problem by using results from simple and widely utilized blood tests, the complete blood count and basic metabolic panel, making it relatively easy and inexpensive to obtain and implement in any clinical setting. 

Developed by Benjamin Horne, PhD, an epidemiologist at the Intermountain Medical Center Heart Institute, and in use throughout the Intermountain system for heart failure patients, the platform allows physicians to identify, in real-time, heart failure and AMI patients "at risk" of re-hospitalization. These patients can then be treated during a first hospital visit to avoid future unplanned admissions. Due in part to the system-wide adoption of this risk score, Intermountain Healthcare has some of the lowest 30-day readmission rates in the country for heart failure and acute myocardial infraction. 

The risk score is gender-specific to provide the best possible personalization of 30-day risk stratification, due to differing risk factors for and clinical needs of women and men. While most readmission scores use data only available at the end of a hospitalization, Intermountain's readmission risk score establishes stratification at the beginning of patient care that can be used during the inpatient admission when clinicians have the most direct influence on the patient's future outcomes.

The Intermountain readmission risk score is an indispensable indicator of exactly which patients are at risk and, when combined with CareCentra's Intelligent Health Platform powered by MoBe Maps (Motivational behavior Mapping), the integrated solution provides a powerful risk identification, segmentation and behavioral modification tool to identify and drive patient activation and behavior change toward the ultimate goal of empowering patient self management.

Unlike other patient engagement solutions that utilize a one-size-fits-all approach to engaging patients with chronic conditions, CareCentra combines a range of data from a patient's reality – clinical, claims, social and behavioral - to classify individuals into one of 16 segments that differ in their propensity for health actions – medication adherence, lifestyle changes, care plan adherence, etc. Over time, using quantitative techniques and feedback from health outcomes, it then persuades patients toward the desired behavior by applying personalized nudges through an intelligent patient activation system to impact clinical outcomes. 

CareCentra's core technology platform, coordinated, multi-modal outreach tools, and online and mobile solutions offer a range of capabilities that support CareCentra's clients' health activation goals - to create both immersive wellness experiences and manage chronic care to ensure a healthier, engaged and activated population.