Our Patient Pattern software takes MDS data or similar assessment data from other sources and from it calculates a Frailty Risk Score. As the score increases so does the risk of poor outcomes including hospitalizations. Some unavoidable hospitalizations are beneficial and resolve the acute need, allowing the patient to return to their baseline state. This happens more often in patients who are only mildly frail, having a physiological reserve for recovery.
Other patients, at higher degrees of frailty, may not benefit from hospitalization or aggressive care. They also may not want to be hospitalized and will do better remaining in the nursing home receiving your high quality care. When the Frailty Risk Score is known professionals have the opportunity to discuss with the patient and family what impact frailty has on recovery and ascertain their wishes for future hospitalizations if an acute illness or trauma occurs. Their wishes should always be memorialized in the medical record and advance care planning documents completed.
Knowing the patient and family expectations and having those wishes documented, and reviewed regularly, helps to avoid late night and weekend emergency transfers – transfers that may not ultimately be wanted or beneficial to the patient. Having a Frailty Risk Score can help frame and support these conversations and decisions.