Adapting risk-assessment tools to find other at-risk patients

2 minute read

Adapting risk-assessment tools to find other at-risk patients

< 1 minute read

El Camino Hospital continually reviews their readmissions data to identify which patients to focus on.

The Issue

When we first looked at our readmissions in 2010, we found that our readmissions were actually lower than the national average. We needed a way to decide where to focus to have the greatest impact.


El Camino is a non-profit hospital in Mountain View, CA. It has 399 beds and serves a primarily affluent and educated population, many of who are non-English speaking or have English as a second language. Their transitions program began in 2012 and is influenced by the Care Transitions Program.

What We Tried

The first thing we did was to stratify our patients by risk, which was determined by age, disposition at discharge, diagnosis, and whether they had a previous admission (within 6 months). The risk tool stratified patients as high, moderate, or low risk for readmission. Our initial focus was on high-risk patients.

We continually review our readmissions data to adjust our focus, though. We try to do root cause analyses on every readmission and then review them every week with hospital leadership. When we identify patterns, we adjust our focus. For example, one summer we noticed that our readmissions from abdominal surgery patients were abnormally high. We decided at one of our weekly meetings to enroll anyone coming in for abdominal surgery.


The case reviews and weekly meetings help us properly target the patients who can benefit the most from transitional care. Rather than stick to a strict risk assessment, we have had flexibility in providing transition services to non-high risk patients as well. In the case of our abdominal surgery patients, their readmission rates went down significantly after we began enrolling these patients in our program.


Completing root cause analyses on every patient takes time. We try to encourage everyone to complete them, but it’s more important to work with patients, so we just do the best we can.

It helps to standardize the case review form to make it easier and faster to go through. Ours has changed a lot and is continuing to evolve.

It really helped us to have hospital leadership and physicians at our case review meetings so that if we identified any patterns or challenges we could address them immediately.

Organizational Background

Organization Name: El Camino Hospital

Location: El Camino Hospital, Mountain View, CA, United States

Organization Type: Non-profit