Overview
Some discharge alerts now show a High Readmission Risk tag. The tag marks patients with a higher estimated potential risk of being readmitted to the hospital after discharge. Patients with the highest potential risk are sorted first, so you can review them as soon as possible after discharge.
Pearl's data science team calculates a potential readmission risk score for each discharge. The tag is based on that score.
Why it's useful
Faster prioritization: Patients with the highest potential risk appear first
Support for quality measures: Reducing readmissions matters for ACO REACH, MSSP, and Medicare Advantage
Works with any discharge: The tag can appear on TFU, TCM, and all other discharge alerts
Where you'll see the tag
The High Readmission Risk tag may be attached to any discharge alert, including Timely Follow-Up (TFU) and Transitional Care Management (TCM) discharges. It can show up in three places:
Prioritized Patient List
Patient Action Pane
Patient View
How the tag affects your list
When the Prioritized Patient List is sorted by urgency score, discharge alerts for patients with the highest potential readmission risk are sorted first.
Important: The tag is an estimate and shouldn't replace clinical judgment.
What the tag is based on
Pearl's data science team calculates a potential readmission risk score for each discharge. The score looks at a patient's recent history, such as prior hospital stays, diagnoses, medications, specialist visits, and social risk factors. [CONFIRM: approve this plain-language input list]
FAQs
Does the tag mean a patient will be readmitted?
No. The tag reflects an estimate of potential readmission risk. It doesn't predict what will happen for an individual patient.
Can the tag appear on TFU and TCM discharges?
Yes. It can be added to any discharge type, including TFU, TCM, and all other discharges.
Can I filter or sort by the tag?
No. You can't filter or sort by the tag itself. When you sort the Prioritized Patient List by urgency score, tagged discharges appear first.
Who do I contact with questions?
Message us on the Pearl Platform or email help@pearlhealth.com.