How is 'advanced illness' defined?

Prescient scores a combination of diagnosis burden, functional decline trajectory, and utilization pattern; the specific thresholds are calibrated with each health system's clinical leadership.

Does this pressure clinicians toward a particular care decision?

No. The worklist identifies patients who may benefit from a goals-of-care conversation — the conversation itself, and any resulting decision, remains entirely with the clinical team and the patient/family.

How does this integrate with existing palliative workflows?

The worklist is designed to feed into each system's existing care-management and palliative referral process rather than stand alone as a separate system.

Can the model account for a patient's documented goals of care?

Yes — documented goals-of-care and code-status history are part of the input data considered when identifying and prioritizing patients.

Platform / Advanced Illness

Advanced Illness Identification

Find the patients who need a goals-of-care conversation — before a crisis forces one.

Prescient identifies hospitalized patients whose trajectory suggests they would benefit from palliative-level attention and advanced-illness care planning, so those conversations happen proactively rather than in a code-status scramble.

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Low

0–39

Moderate

40–64

High

65–84

Critical

85–100

The Problem

Why this matters

Palliative and advanced-illness referrals are frequently triggered too late — often during an acute decline — because the patients who would benefit aren't systematically identified across a busy census.

Inputs

What the model scores

Diagnosis and comorbidity burden across the current and prior encounters
Functional status and trend in clinical decline
Utilization pattern (readmissions, ICU transfers, escalations)
Documented goals-of-care and code-status history

Workflow

Where it shows up

Care management and palliative teams receive a prioritized, risk-ranked worklist
Risk band is paired with the specific factors driving the score for a faster, better-informed conversation
Integrates with existing care-management workflows rather than a standalone list

A Typical Scenario

How This Plays Out

Day 1
Admission
A patient with multiple comorbidities is admitted. Diagnosis burden and prior utilization pattern are already visible in the EHR, but not yet flagged for palliative review.
Day 1
Prescient scores the encounter
Comorbidity burden, functional trend, and utilization history combine into a Moderate advanced-illness risk score, added to the care management worklist.
Day 2
Care management reviews the worklist
The palliative liaison sees the patient prioritized with the specific contributing factors, rather than discovering the case during a later chart review.
Day 2
Goals-of-care conversation happens proactively
The care team initiates a goals-of-care conversation while the patient is stable — not during a subsequent acute decline.

Data Flow

How Data Becomes a Risk Score

Encounter Data

Diagnosis burden, functional status, and utilization history from the EHR.

Advanced-Illness Scoring

Trajectory and comorbidity signals combine into a risk band.

Care Management Worklist

Prioritized, risk-ranked list reaches palliative and care teams.

Proactive Outreach

Goals-of-care conversation happens ahead of a crisis.

The Difference

Without vs. With Advanced Illness

	Without Prescient	With Prescient
Identification timing	Referral often triggered during an acute decline	Systematic identification across the full census, before a crisis
Prioritization	Manual chart review to find candidates	Risk-ranked worklist with contributing factors attached
Conversation timing	Goals-of-care discussion happens reactively	Conversation happens proactively, while the patient is stable
Team coordination	Palliative, care management, and hospitalist teams working from separate views	One shared, risk-ranked worklist across teams