What We Tried

At first we considered some “off-the-shelf” risk assessment tools, but none of them seemed to be particularly predictive of risk of readmission. We then hired a statistician to look specifically at our data to develop prediction models, but those results weren’t stellar either. Rather than continue exploring more complicated models, we decided to use basic higher risk indicators based on chronic medical conditions, a patient of the community clinic, or a history of prior readmissions in the last six months, as well as some subjective assessment by our staff such as “limited social support.”

Our coaches then use the 13-question Patient Activation Measure (http://www.insigniahealth.com/ha/measure.html) while a patient is still in the hospital to determine if they might benefit from coaching. This is based on the patient’s level of “activation” or ability to advocate for their own needs. Our mobile device provides instantaneous scoring of the results of the measure. The most activated patients likely don’t need coaching. The least activated ones need much more support than we could offer, so we refer them to more assistive services that include additional assessment, patient teaching, transportation, or advocacy. The patients in the middle are the ones we focus on—the ones who have the motivation or potential to build their self-advocacy skills, but just need a little support from the coach to help them get there.