RightCare Solutions

RightCare Solutions

Transforming the way clinicians identify high-risk patients and make referral decisions about who needs post-acute care

Background & Goal

More than a decade of funded research to Dr. Kathryn Bowles’ interdisciplinary team revealed both a lack of standards and great variation in the referral decision making process of hospital discharge planners for older patients from acute care to post-acute care (PAC). With over 13 million older adults dependent on referral decisions made by discharge planners each year, many older adults were discharged home to self-care with multiple unmet needs and risk factors for poor outcomes. The Bowles’ team demonstrated that patients who needed post-acute care but didn’t receive it were readmitted five times more often than similarly situated patients who did receive post-acute care. Armed with this troubling data, Dr. Bowles’ team obtained NIH funding from the National Institute of Nursing Research to build and test a solution.

The resulting nurse developed and designed Discharge Decision Support System (D2S2) is transforming the way clinicians identify high-risk patients and make referral decisions about who needs post-acute care.

Project Description

Unlike most risk screening tools that rely on administrative data and medical diagnoses that lack acceptable sensitivity and specificity to accurately identify those at risk, the Discharge Decision Support System is an evidence-based six-item screening tool that uniquely focuses on the factors that influence the self-care ability of patients once they are discharged. 

More Information

Kathryn H. Bowles, PhD, RN, FAAN, FACMI

bowles@nursing.upenn.edu
215-898-0323

One Page Summary

The D2S2 assesses factors that are highly predictive of a patient’s ability to perform self-care, including the availability of a caregiver.  The system is built with “smart” technology that effectively learns from the patients, their situations, and the health care received to become more accurate over time. By more accurately assessing the PAC needs of older adults, the D2S2 improves patient care and reduces hospital costs from readmission, both in care and penalties. The algorithm has been successfully commercialized by RightCare Solutions, a software company co-founded by Dr. Bowles.

Evidence of Success

The evidence supporting the effectiveness and benefits of the Discharge Decision Support System continues to grow:

  • In three prospective studies with hospitalized older adults, patients who scored high on the D2S2 (indicating increased need for PAC) were significantly older, prescribed more medications, had more co-morbidity conditions, had more frequent doctor visits, and had more frequent hospital admissions in the preceding six months than patients who scored as low risk;
  • In a pre-post study comparing patients in usual care (without D2S2) to patients using D2S2, the number of patients refusing post-acute care decreased significantly from 31% to 23%, suggesting clinicians offered referrals more appropriately resulting in more patients agreeing as to the need;
  • Results published in Professional Case Management showed a 6% and 9% reduction in both 30 and 60 day readmission rates respectively when comparing usual care to D2S2 implementation; Both periods represent a 26% relative reduction in readmissions.
  • An NINR funded study by the Small Business Innovation Research mechanism resulted in significantly fewer 30-day readmissions for high-risk patients from the control to experimental phases (22.2% to 9.4%, p<.05). Overall (combining high and low risk patients), the experimental phase achieved a 33% relative reduction in 30 day readmissions (13.1% to 8.8%) and sustained a 37% relative reduction at 60 days.