TY - JOUR
T1 - Deep Learning Model for Predicting High-Risk Transitions of Care Using Discharge Summaries, Medication Reconciliation Records, Follow-Up Appointment Status, Home Support Indicators, and Social Risk Variables
AU - Alejandro Torres
AU - Miguel Fernandez
JF - Journal of Health Informatics and Digital Systems
JO - J. Health Inform. Digit. Syst.
SN - 3149-8973
Y1 - 2024
VL - 4
IS - 2
DO - 10.68159/j256166969
SP - 97
N2 - High-risk transitions of care remain a major source of preventable readmissions, emergency department use, medication harm, and post-discharge deterioration. Existing risk tools often simplify the transition period into structured clinical variables and may not fully represent clinical complexity, social vulnerability, medication safety, or home support. Discharge planning commonly depends on generic risk scores, clinician judgment, and incomplete structured fields. These approaches may overlook risk signals embedded in discharge summaries, medication reconciliation records, follow-up plans, case management documentation, and social risk screening. This manuscript proposes a conceptual deep learning model for predicting high-risk transitions of care. The model is designed to fuse discharge summary narratives, medication reconciliation data, follow-up appointment status, home support indicators, and social risk variables into a unified transition risk score. The proposed architecture combines a clinical language encoder for discharge summaries with a structured-data network for medication, follow-up, home support, and social risk features. These representations are integrated through a multimodal fusion layer that would generate a patient-level risk estimate at the point of discharge. Conceptually, the model could identify patients at elevated risk of readmission, emergency department use, or adverse post-discharge outcomes who might be missed by traditional scores. It would also be expected to highlight clinically interpretable risk drivers that could support targeted transitional care planning. A multimodal deep learning model could strengthen precision transitional care by integrating clinical, logistical, medication-related, and social dimensions of risk. Such a model could help discharge teams prioritize intensified interventions for patients most vulnerable to unsafe care transitions.
UR - https://cirpublications.com/j256166969
ER -