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Population Health Advisor

Lower 30-day readmissions

Lowering 30-day readmissions is critical to improving patient outcomes, but if your readmission measures are inaccurate or require manual calculations to correct discrepancies, you could be missing opportunities to prevent readmissions, improve patient care, and reduce costs.

A Diver Platform-based application can automate readmissions reporting. Using Diver to translate the readmissions specifications into business rules and measures can result in accurate and timely daily readmission reports plus information about those patients who are frequently readmitted. Together, these reports can help medical teams and case managers to optimize patient care.

Once you have accurate reporting of readmissions, you can begin to understand why patients are returning and how post-discharge follow-up care can be improved. With analytics, implementing process changes and improving patient follow-up improves clinical outcomes, especially for high-risk patients who are frequently readmitted.

Access to Standard Out-of-the-Box Measures

The Population Analytics Advisor application comes with out-of-the-box measures that can be quickly implemented in your hospital. Measures categories include:

  • Total Admissions
  • Total Discharges
  • Total Discharge Days
  • Acute Discharges
  • Acute Discharge Days
  • Acute ALOS
  • IP Admissions
  • IP Discharges
  • ED Visits
  • Physician Office Visits
Diabetes Measures
  • Total Population
  • Diabetes Registry Population
  • Diabetes Registry Population %
  • Diabetic Patients
  • Diabetic Patients %
  • Diabetic Patients Age 18-75
  • Diagnosed Diabetes Patients
  • Diagnosed Diabetes %
  • Diagnosed Diabetes with CMs Patients
  • Diagnosed Diabetes with CMs %
  • Potentially Undiagnosed Diabetes Patients
  • Potentially Undiagnosed Diabetes %
  • Pre-Diabetes Patients
  • Pre-Diabetes %
Lab Orders / Results
  • Patients with Borderline High A1c (5.7%-6.5%)
  • Percent Patients with Borderline High A1c (5.7%-6.5%)
  • Percent Patients with High A1c (>=6.5%)
  • Patients with High A1c (>=6.5%)
  • Patients with Valid A1c Result
  • Patients with Valid Glucose Result
  • Patients with Glucose>150
  • Percent Patients with High Glucose
  • Patients with Valid BMI Result
  • Patients with BMI>25
  • Percent Patients with High BMI
  • Patients with Valid LDL Result
  • Patients with LDL>100
  • Percent Patients with LDL>100
  • Patients with Valid Creatinine Result
  • Patients with High Creatinine (>1.21)
  • Percent Patients with High Creatinine (>1.21)

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