Table 2.

Readmissions risk estimation and summary of associated workflows for various stakeholder groups at the University of California San Diego

Stakeholder	Current method(s) of assessing readmissions risk	Existing workflows around reducing readmissions
Case management	LACE+	LACE+ used to guide post-discharge appointment scheduling, detailed chart reviews, triage for skilled nursing facility referrals, and prioritization of discussion during rounds focused on barriers to discharge and interdisciplinary care.
Social work	LACE+	Consult-driven, so assessments were based on consultation requests, rather than on risk scores. However, high LACE+ scores did prompt more detailed chart reviews.
Inpatient pharmacy	Custom pharmacy institutional risk score	The custom risk score was used to allocate pharmacy technician resources and prioritize discussions on interdisciplinary rounds.
Outpatient pharmacy	No formal assessment	No formal workflows
Population health services organization (PHSO)	Institutional general risk score (custom risk score previously developed by our health system), LACE + , patients with new diagnoses, elderly	Interventions for high-risk patients included assignment to a complex case management team, remote patient monitoring, home visits, mobile outreach (e.g., text reminders), and detailed chart reviews for identification of additional needs.
Transitional telephonic nursing	LACE + , health literacy, social determinants of health	Initial outreach did not involve risk stratification, as all patients were contacted by the telephonic nursing team after hospital discharge. However, high-risk patients identified by the listed criteria received additional outreach to connect them to community resources.
Inpatient nursing	No formal assessment	No formal workflows
Physicians	No formal assessment	No formal workflows