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In an effort to improve discharge outcomes for patients who require post-acute care (PAC), a team of researchers from the University of Pennsylvania School of Nursing (Penn Nursing) developed, validated, and tested a two-step clinical decision support (CDS) algorithm called Discharge Referral Expert System for Care Transitions (DIRECT). DIRECT helps clinicians identify patients in need of PAC and suggests whether skilled home care or facility level care is best.

Hospital clinicians strive to effectively refer patients who require PAC, but their discharge-planning processes often vary and are typically not evidence-based. In an effort to lessen readmission risk after discharge and achieve the best possible outcomes for patients, hospital-based clinicians are creating more intentional and thoughtful discharge plans for patients who require PAC.

Penn Nursing researchers developed the DIRECT CDS using structured patient data drawn from electronic health records. The team then conducted a four-month control phase of study without CDS with more than 3,000 patients aged 55 and older, followed by a six-month intervention phase of study when clinicians received DIRECT CDS advice from clinical experts for more than 5,000 patients. They compared readmission rates between the two phases after controlling for differences in patient characteristics.

Kathryn H. Bowles, PhD, RN, FAAN, FACMI, Professor of Nursing, the van Ameringen Chair in Nursing Excellence, tells Eurekalert.org, “Health care providers are increasingly pressured by policies and initiatives to decrease health care utilization and contain costs. Policy requirements and bundled payment programs seeking the least costly site of care may limit options and result in patients not getting the optimal level of PAC needed to prevent poor discharge outcomes. We developed DIRECT to improve the patient-centered discharge process using an evidence-based, objective tool.”

The DIRECT CDS algorithm proved valuable in providing advice on whom to refer and the level of care, and showed case managers the important patient characteristics that led to that advice such as fall risk and who declined in activities of daily living function. To learn more about Penn Nursing’s new decision support tool to improve discharge outcomes for patients who require post-acute care, visit here.

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