Proactive Patient ACuity sTewardship (PACT) trial

Primary purpose is to evaluate the (a) difference in clinical outcomes, e.g., 30 day ReAdmissions (30 dReAm) and supportive care consult rates before and after implementation of respective prompts in the Electronic Medical Record (EMR) utilizing Rothman Index (RI) monitoring thresholds for patients undergoing SMH hospitalist care and (b) 30 dReAdm rate in patients who continue to be monitored with RI after discharge to SMH-Nursing Rehabilitation Center. A historical cohort will be retrospectively matched with the prospective sample in PACT trial. Secondary purpose of the study is to demonstrate that findings derived from RI monitoring protocols also can contribute to building a “learning health system” that can leverage EMR data science methods to characterize clinical patterns before positive and adverse clinical events and to identify trends to improve patient care and safety across the acute/post- acute care continuum.

A secondary purpose is to conduct a sub-study to test the agreement of a registered nurse with study participants’ inventory of their body systems that is obtained through a series of questions to identify signs and/or symptoms which they are experiencing. A similar body system inventory is used to compute the RI. Independent living residents and residents undergoing rehabilitation care at Plymouth Harbor will be asked to participate. The goal is to transform the RI into a self-assessment tool that engages 
patients in tracking and reporting their condition. Incentivizing meaningful patient engagement may result in a bond between provider and patient to optimize care and reduce unnecessary admissions to the hospital.