Creation Of Individualized Care Plans In High Risk Oncology Patients: A Team Based Model To Decrease Unnecessary Hospitalizations And Ed Utilization

Will an individualized care plan (ICP) for patients with the highest utilization better address the complex needs of this patient population and subsequently reduce preventable admissions, readmissions, and emergency department (ED) visits? An interdisciplinary care team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, nurse coordinators, advanced practice providers/nurses. On a bimonthly basis, adult patients (>18 years) with at least 2 unplanned hospital readmissions during the previous 60 days were identified. Exclusions were planned chemotherapy and hospice admissions. Patients that met inclusion criteria were reviewed by the ICT and identified opportunities specific to the needs of each patient. Recommendations from the ICT were communicated to their respective providers. 226 hospitalizations and 163 ED visits for 36 individual high-risk patients were evaluated. All of the patients had relapsed/refractory hematologic or metastatic solid tumor disease. Median age was 55.2 (range 20-74). 50% were female, 42% had hematologic malignancies and 58% had solid tumor malignancies. After implementation of the ICP, hospitalizations decreased from 0.89 per patient month (ppm) to 0.26 ppm, with average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Creation of individualized care plans for high utilizing cancer patients decreased the number of hospitalizations, ED visits, unplanned readmissions and length of stay in all disease groups.