Readmission Risk Assessment Tool


To develop a new instrument, based on CREATION Life principles, for screening hospitalized patients at high risk for preventable readmission and identifying modifiable risk factors to address across the care continuum.

Key Study Personnel:

Hong Tao, PhD, RN - Principal Investigator
Patricia Robinson, PhD, ARNP - Sub-Investigator
Pamela J. Jennelle, MS - Coordinator
Ashley Kohrt, MBA - Lead Coordinator
David Richard, PhD - Independent Consultant

Number of Participants:

  • Phase 1: 620
  • Phase 2: 620

Study Population

Participants who meet the following inclusion criteria are recruited from the inpatient setting at AdventHealth Orlando:

Inclusion Criteria:

  1. Primary or secondary admission diagnosis of heart failure, chronic obstructive pulmonary disease, acute myocardial infraction, coronary artery bypass graft, pneumonia, total knee or hip replacement, or stroke.
  2. Age 21 and over
  3. Able to provide informed consent
  4. Able to speak and read English
  5. Able to complete and electronic survey or relay answers to questions to another party who may complete the survey for the participant
  6. Resides in Central Florida and anticipates continued residence in Central Florida for the next 120 days
  7. Planned discharge to a non-hospital or residential care environment

Exclusion Criteria:

  1. Under age 21
  2. Does not speak or read English
  3. Permanent residence is outside Central Florida
  4. Not of cognitive capacity to provide valid responses
  5. Dementia or cognitive impairment that renders subject unable to provide informed consent
  6. Prescribed a known psychoactive medication that might reasonably affect the ability of the participants to provide valid responses




Patients who have given informed consent are asked to complete an 82-question assessment including questions about their mental, physical, and spiritual well-being. The participant’s medical record will be reviewed for instances of readmission up to 120 days post- discharge. Demographic and health information will also be collected from the medical record.

Phase 1 comprises initial item development and measurement validation of a new tool for identifying hospitalized patients at high risk for preventable readmission.  Primary tasks include item construction and content validation, data collection, analysis, and instrument refinement.

Phase 2 involves administering the refined, condensed instrument to a new group of patients to determine final item content for the instrument, its factor structure, and its predictive validity.

Current Status:

Phase 1: Completed January 2018
Phase 2: Scheduled May 2018

Targeted Completion Date:

December 2018

Additional Information:

Questions about study:
Dr. Patricia Robinson