Augmenting a Transitional Care Model With Artificial Intelligence Decreased Readmissions.

Zenobia Brown¹, Danielle Bergman², Liberty Holt², Kelly Miller², John Frownfelter², Hallie Bleau³, Anne Flynn⁴, Trever Ball³

¹Northwell Health, Health Solutions Population Health Management, Manhasset, NY, USA. Electronic address: Zbrown2@northwell.edu.

²Jvion, Suwanee, GA, USA.

³Northwell Health, Health Solutions Population Health Management, Manhasset, NY, USA.

⁴Northwell Health, Health Solutions Population Health Management, Manhasset, NY, USA; Hofstra/Zucker School of Medicine, Hempstead, NY, USA.

PubMed DOI

Abstract

OBJECTIVES: Evaluate if augmenting a transitions of care delivery model with insights from artificial intelligence (AI) that applied clinical and exogenous social determinants of health data would reduce rehospitalization in older adults. DESIGN: Retrospective case-control study. SETTING AND PARTICIPANTS: Adult patients discharged from integrated health system between November 1, 2019, and Febru…

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