Transition Care Navigation Utilizing a Predictive Model (LACE+) to Impact Readmission Rates and Transfer of Care From Inpatient to Outpatient: A Programmatic Research Study

Background Oncology patients, with new or established diagnoses, are often overwhelmed when hospitalized, and focusing on discharge plans and process can be very frustrating. Lack in coordination of care between the hospital team, patient, family, and primary medical oncologist can lead to extended length of stay, delay in care, and potential hospital readmission. The cost of avoidable readmissions or preventable adverse events are burdening the healthcare system. Our goal is to improve coordination of care and communication that will have an impact in these areas with the implementation of a transition care manager/navigator (TCN) and an enhanced predictive model (LACE+).

Method Utilizing the established LACE index tool, which is designed to identify patients who are at risk for readmission or death within 30 days of discharge, is based on four factors: Length of stay, Acuity of admission, Comorbidities, and Emergency room visits. A 2-year data analysis looking at readmission patterns for our oncology patients lead to the enhancement (oncology focus) of the LACE tool, which we refer to as LACE+. The LACE+ tool stratifies the oncology patient readmission risk as high, medium, or low, and the TCN uses this tool to prioritize patients. These patients are identified and discussed during multidisciplinary rounds, and potential barriers to a successful discharge without readmission are addressed. The high risk patients are called 24-hours post discharge and those at medium risk are contacted within 72 hours.

Results Preliminary results have shown the 24-/72-hour phone call TCN interventions have been positively received by patients.  Interventions include medication reconciliation and adherence, prior authorization, referral to transitional care clinics (TCC), post discharge follow-up, side effect management, referral to social worker, follow-up with homecare agency, and emotional support. The TCN also evaluates patients for TCC led by APNs prior to reestablished primary oncologist visits.

Initial 6-month data revealed decreased readmissions, increased referrals to TCC, and decreased utilization of emergency department (ED).

Conclusion Implementation of a TCN was shown to improve care coordination in transition from inpatient to outpatient, decrease ED utilization, and decrease readmissions for our oncology population.

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van Walraven C, Wong J, Forster AJ. LACE+ index: extension of a validated index to predict early death or urgent readmission after hospital discharge using administrative data. Open Med. 2012;6(3):e80-e90.