New proprietary algorithms evaluate risk of readmission and hospice eligibility to identify and manage high-risk patients as they move through the continuum of care

WellSky, a leading health and community care technology company, today announced new predictive analytics capabilities in its CarePort Connect solution to help providers improve cost and quality by reducing skilled nursing facility (SNF) readmissions and optimizing end-of-life care transitions. These algorithms are part of the new 360° Risk Summary, enabling providers to pinpoint in real time when nursing home patients’ risk of rehospitalization rises and when they may benefit from a hospice evaluation.

“It’s more important than ever for providers to consider the many factors that contribute to a patient’s health and recovery,” said Dr. Lissy Hu, president, connected networks at WellSky. “By modeling millions of patient journeys – both clinical and nonclinical factors – and taking into account the hundreds of characteristics of the providers caring for those patients, we’re able to present the most comprehensive and up-to-date view of the patient. The 360° Risk Summary allows providers to consider both patient- and provider-level factors when determining which patients would benefit from additional intervention.”

Hospice care is an impactful, yet often underutilized setting of care. It can be challenging for care navigators to determine when and which patients would benefit from intervention. As part of the 360° Risk Summary, the new predictive analytics model for hospice suitability considers demographic and diagnosis data, care utilization history, and post-acute provider characteristics to identify and triage patients who are likely eligible and could benefit from hospice care.

The new predictive analytics model for SNF hospitalization risk takes the whole patient into consideration and renders readmission risk based off clinical and non-clinical data that goes beyond data found in the electronic medical record. This includes patient diagnosis data, prior hospitalizations and rehospitalizations from SNFs, social determinants of health factors, and SNF quality scores.

"With this new SNF hospitalization score, we can transform our approach to readmission and drive more informed care decisions,” said Rona Shuchat, senior director, network integration, care coordination at UMass Memorial Health. “Now that we have a shared view of patient risk with our post-acute partners, we have the ability to run reports to identify and prioritize patients based on a comprehensive view of risk factors, enabling us to better collaborate with our facilities."

With the 360° Risk Summary, providers can now identify at a glance which at-risk patients should be prioritized for intervention. The 360° Risk Summary supports providers in making data-driven decisions for their patients to mitigate readmission risk, manage resources, and support patients’ successful post-acute recoveries.

Learn more about how the 360° Risk Summary can enhance your organization’s ability to provide the right care at a lower cost to achieve improved results.

About WellSky^®

WellSky is one of America’s largest and most innovative healthcare technology companies leading the movement for intelligent, coordinated care. Our proven software, analytics, and services power better outcomes and lower costs for stakeholders across the health and community care continuum. In today’s value-based care environment, WellSky helps providers, payers, health systems, and community organizations scale processes, improve collaboration for growth, harness the power of data analytics, and achieve better outcomes by further connecting clinical and social care. WellSky serves more than 20,000 client sites — including the largest hospital systems, blood banks, cell therapy labs, home health and hospice franchises, post-acute providers, government agencies, and human services organizations. Informed by more than 40 years of providing software and expertise, WellSky anticipates clients’ needs and innovates relentlessly to build healthy, thriving communities. For more information, visit wellsky.com.

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