Readmission Risk Based on Debility and Psychosocial Measures: The Western 9 Algorithm

Area of Science:

• Health Services Research
• Public Health
• Chronic Disease Management

Background:

• Psychosocial determinants like food insecurity and housing instability significantly impact health outcomes.
• Effective patient profiling is crucial for managing chronic conditions and reducing hospital readmissions.
• Existing risk algorithms may not fully capture the impact of social determinants of health.

Purpose of the Study:

• To evaluate the added value of the Western 9 screening questions in predicting hospital readmission risk.
• To determine if psychosocial risk profiles enhance existing risk prediction models.
• To assess the discriminative power of the Western 9 tool within a chronic care initiative.

Main Methods:

• Development of the Western 9 screening tool based on psychosocial measures.
• Categorization of patient risk into Low, Medium, and High profiles using aggregate scores.
• Comparison of a baseline risk model with a model incorporating the Western 9 risk profiles.

Main Results:

• Inclusion of psychosocial risk profiles significantly improved model fit.
• Enhanced calibration was observed when using the Western 9 risk profiles.
• The Western 9 questions demonstrated additional discriminative power beyond existing algorithms.

Conclusions:

• The Western 9 screening tool effectively adds discriminative power to readmission risk algorithms.
• Psychosocial factors, when systematically screened, are valuable predictors in chronic care management.
• Further refinement, such as developing weighted indices, could optimize the Western 9 tool's performance.