• Tool: Care Transitions Risk Assessment

    Dec 09, 2013

    A risk assessment tool is helping nurses proactively identify patients at risk of readmission. 


    To identify older adults at high risk of readmission, OSF HealthCare, an eight-hospital system in Peoria, Ill., uses an assessment tool based on the Society of Hospital Medicine’s Better Outcomes by Optimizing Safe Transitions (BOOST) project. 

    The tool covers “8 Ps” to assess during transitions (e.g., from acute to post-acute care): 

    • Presentation of patient
    • Patient support
    • Poor health literacy
    • Psychological issues
    • Prior hospitalization
    • Principal diagnosis
    • Palliative care
    • Problem medications

    Access the OSF tool: Care Transitions Risk Assessment

    OSF has reduced readmissions from skilled nursing facilities to 11 percent in 2013 (from 27 percent in 2012) using a combination of strategies. Visits to the ED also have been cut by more than half.

    Learn more about OSF’s efforts to integrate with post-acute providers in the Leadership feature, “Bridging Acute and Post-Acute Care.”