"Repeated readmissions can indicate gaps in discharge planning, care coordination, medication review, patient education, or post-discharge follow-up."
Thirty-day readmission is also a hospital quality indicator. Under CMS HRRP, excess readmissions can reduce Medicare payments by up to 3%, while AHRQ/HCUP reported an average readmission cost of approximately $15,200.
That is why this project asks: can hospitals identify high-risk diabetic patients before discharge — and act earlier?
Source: CMS HRRP and AHRQ/HCUP, cited in project report.
The system serves two distinct user personas, each with different needs and objectives.
Aggregates SQL queries into live high-level trends, financial exposures, and clinical penalty metrics.
Open Live BI Dashboard
Predicts 30-day readmission risk, maps drivers, and coordinates care checklists via clinical copilot.
Open Patient AI PortalThe Copilot does not answer from vibes. A RAG layer retrieves patient context, then model evidence and SHAP signals are assembled before generating a discharge-focused response.
The planner asks: "Review whether Olivia Patel is ready for discharge"
Encounter details, labs, diagnosis history, medication status, and discharge context are retrieved.
Model drivers become evidence: prior utilisation, A1c context, age group, and diagnosis burden.
The answer explains risk, highlights uncertainty, and suggests what to review before discharge.
I can review structured clinical records, translate risk predictions, and evaluate discharge readiness. Ask a free-form question or use the quick actions below:
This patient is stratified as Medium Risk (11.55%) with prior utilization level low and discharge planned to home.
The patient's advanced age and recent history of inpatient utilization are visible factors in the risk assessment that should be reviewed during discharge planning.
The clinical burden remains at a medium level with a three-day length of stay; current documentation appears adequate for the complexity level.
While maximum glucose levels remain normal, the lack of HbA1c testing is worth checking as a planning consideration for long-term diabetes management.
Medication reconciliation is complete, but the recommendation for diabetes education should be reviewed before discharge to ensure adherence with the current repaglinide regimen.
Discharge to home is currently planned with standard follow-up, and no major social support concerns were identified in the planning notes.