PraPlus screens for risk of repeat admissions

Consider this tool for your elderly patients

A survey tool developed recently at the University of Minnesota School of Public Health in Minneapolis may prove useful to you. The PraPlus determines older patients’ risk of repeat hospitalization and comprises a screening questionnaire and a formula for deriving a risk score. It identifies older patients who may benefit from interventions designed to avert health crises and the need for expensive care.

Organizations determine the thresholds for risk categories according to the level of risk they wish to identify. For example, it is known that people with PraPlus scores of 0.5 or greater have twice the hospital days and costs of those with scores below 0.5. Accordingly, an organization using PraPlus could select 0.5 as its threshold for high risk. Different populations are stratified into different percentages of high-, moderate-, and low-risk people. About 7% of general elderly populations and 18% of Medicaid elderly populations have PraPlus risk scores of 0.5 or higher.

Thresholds for risk categories can be established using either of two methods:

risk-driven — preselecting a risk score as the cutoff for further intervention;

resource-driven — selecting cutoffs based on the number of enrollees that can be served in light of the resources the institution is prepared to devote to a given intervention. This is more pragmatic and helpful in allocating limited resources.

For example, consider this scenario for a resource-driven threshold method: An organization wishes to provide a high-intensity case management program to its highest-risk senior patients, and its budget allows for 10% of its members to receive the benefit. In addition, the budget would allow a lower-risk additional 25% of its members to take part in targeted prevention and health promotion programs. To establish thresholds for the high-, moderate-, and low-risk categories using the resource-driven method, the organization would first administer the screening questionnaire to its entire elderly population. The 10% of members with the highest risk scores would be classified as high risk and would enter the high-intensity case management program. Those scoring in the 65th to 90th percentile would constitute the moderate-risk group and qualify for the less intensive interventions.

Questions in the instrument deal with age, gender, state of health, state of mind, living conditions, ability to take care of oneself, and financial status. Answers to questions 1-6 and 16-17 in the questionnaire are used to calculate the PraPlus risk score. Answers to questions 7-15 are optional and provide a bridge to the assessment process as well as information useful for the medical record. They also may result in a patient being classified into Medicaid and institutional rate cells, leading to higher Medicare reimbursement.

The tool can be understood by respondents with an eighth-grade education and can be administered in person, by telephone, or by mail. It takes about seven minutes to fill out. Licensing fee for PraPlus is $500 per year. For more information, contact Lynette Sylvain at the Center on Aging at the University of Minnesota at (612) 625-8954.

Related Reading

Pacala JT, Boult C, Reed RL, et al. Predictive validity of the Pra instrument among older recipients of managed care. J Am Geriatr Soc 1997; 45:614-617.

Boult C, Pacala JT, Boult LB. Targeting elders for geriatric evaluation and management: Reliability, validity, and practicality of a questionnaire. Aging Clin Exp Res 1995; 7:159-164.