Abstract
The Transitional Care (TC) Quality Improvement and Innovation Project was launched to ensure a safe and comprehensive transfer of elderly patients as they navigate levels of care. It aims to improve overall outcome and as such reduce the 30 day post-discharge, unplanned hospital readmission rate. In order to achieve these objectives, PRASS: Patient Risk Assessment and Stratification Screening tool (PRASS) was developed to provide a multidimensional and multiaxial approach to classifying patient's clinical status. Through an innovative method of utilizing parameters and their clinical implications as supported by evidenced based medicine, PRASS is used to assign scores to patients on three risk of readmission levels: Low (<3), Intermediate (3-5) and High (6 and above).
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