Doing complex risk assessment with a few questions and your gut

3 minute read

Doing complex risk assessment with a few questions and your gut

< 1 minute read

Marin General uses a simple questionnaire and intuition to determine whether patients can benefit from coaching.

The Issue

When we first began, we wanted this magic tool where you could input a few patient criteria, press “assess”, and it would tell you whether they were high risk. Unfortunately it’s not as easy as that. Part of the challenge is that risk assessment depends on so many different criteria. It gets even more complicated when you try to include social determinants, which have proven to be very indicative but are a lot more subjective.

Another challenge was that we needed a tool that could be used at the bedside to assess the risk of readmission of our patients, regardless of age, in a minimal amount of time. Nurses didn’t have the time to ask a ton of questions, then go to a computer and plug into multiple databases to pull out the necessary data. We needed something that we could use upon admission so that we could plan a patient’s care with their risk assessment in mind.


Marin General is a non-profit hospital in Greenbrae, CA. It has 250 beds and serves a mainly affluent suburban/rural population with pockets of low-income Latinos, African-Americans, and state prison inmates. Their transitions program began in 2011 and is influenced by the Care Transitions Program and Project RED.

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 ( 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.


The Patient Activation Measure is a quick and easy questionnaire that can be administered at the bedside. It gives a general picture of a patient’s ability to take care of themselves and then our nurses can make the judgment call of whether the patient can benefit from coaching.

Organizational Background

Organization Name: Marin General Hospital

Location: Marin General Hospital, Bon Air Road, Kentfield, CA, United States

Organization Type: Hospital