Successful Posthospitalisation Oncology Workflow Implementing Lace+ Score To Stratify and Reduce Readmissions Within a Safety-Net Hospital

Authors

• Cindy M Pabon
• Janine Wong
• Marcela Perez
• Jessica Jimenez-Abarca
• Lianchun Xiao
• Lymesia Jackson
• Anne Park
• Anjali Lankford
• Vinita Akula
• Saumil Datar
• Taylor Hopper
• Yaser Alkhatib
• Terri Earles
• Tejal Patel

Publication Date

2-13-2025

Journal

BMJ Open Quality

DOI

10.1136/bmjoq-2024-003068

PMID

39947738

PMCID

PMC11831318

PubMedCentral® Posted Date

2-13-2025

PubMedCentral® Full Text Version

Post-print

Abstract

Background: Patients with advanced cancers visit the emergency room and get hospitalised frequently, with potentially half of these visits being avoidable. Our institution provides comprehensive, low-cost cancer treatment to a safety-net population in Texas. We performed a retrospective review of hospital readmission patterns amongst our oncology patients and developed a posthospitalisation workflow to reduce readmissions.

Method: Following discharge, oncology patients were risk stratified based on their Length of stay, Acuity of admission, Charlson comorbidity index score and Emergency department visits+index in the past 6 months. The higher the score, the quicker the outpatient oncology follow-up. In addition to addressing acute issues related to hospitalisation, patients were also able to receive newly translated resources while in clinic.

Results: The preintervention 30-day-readmission rate was 17.3% (June 2022-December 2022) (95% CI 13.4% to 21.8%). Meanwhile, the postintervention 30-day-readmission rate was 14.7% (June 2023-December 2023) (95% CI 10.9% to 19.2%). While a 2.6% reduction in readmissions was achieved, this decrease was not statistically significant (-2.6%; 95% CI -8.4% to 3.2%; p value=0.375). Emergency use utilisation decreased from 90% to 15%.

Conclusions: Our team was able to facilitate and coordinate outpatient care for oncology patients following hospitalisation. The expedited care allowed providers to ensure that the care plan after hospitalisation was well understood and accessible to the patient. Furthermore, language-appropriate resources were provided to patients at that time. Our intervention was feasible, easy to implement and quick to produce tangible improvements in patient care. More time is needed to determine whether this will create a statistically significant impact on readmission rates.

Keywords

Humans, Patient Readmission, Retrospective Studies, Workflow, Texas, Female, Male, Middle Aged, Safety-net Providers, Aged, Medical Oncology, Neoplasms, Emergency Service, Hospital, Quality improvement, Ambulatory care, Continuity of Patient Care, Patient-centred care, Patient Discharge

Published Open-Access

yes

Recommended Citation

Pabon, Cindy M; Wong, Janine; Perez, Marcela; et al., "Successful Posthospitalisation Oncology Workflow Implementing Lace+ Score To Stratify and Reduce Readmissions Within a Safety-Net Hospital" (2025). Faculty, Staff and Student Publications. 3517.
https://digitalcommons.library.tmc.edu/uthmed_docs/3517