Supporting high-risk oncology patients with an outpatient transitional care management program.

Abstract

313 Background: Transitional Care Management initiatives (TCM) financially support comprehensive outpatient followup in the first 30 days after acute care discharge. TCM programs require patient contact within 2 days of discharge, an outpatient appointment within 7-14 days, patient education, and moderate-high complexity medical decision-making that supports successful outpatient transition. To date, TCM is often utilized to provide additional reimbursement for qualifying primary care post-discharge followup, but could be applied to align incentives in busy oncology practices. We present a novel application of TCM to enhance post-discharge cancer care with the goal of reducing readmissions for high-risk oncology patients. Methods: We identified patients discharged from our health system’s cancer hospital with a “Highest” risk of readmission as determined by an internally developed machine learning clinical algorithm built into the EMR. Patients were targeted with a post-discharge phone call within 48 hours offering an in-person or telemedicine appointment within 72 hours. The Transitional Care Clinic (TCC) visit guidelines promote connection to ancillary services such as physical and occupational therapy, medication management, and dietetics. The TCC can offer interventions to address emergent medical needs such as fluids, transfusions, and symptom management. Results: In the first three months of the TCC program, the 30-day readmission risk algorithm identified 136 cancer patients discharged from the designated cancer hospital in the “Highest” readmission risk category. 121 of those patients were previously admitted within one year. 72 of the 136 “Highest” risk patients were referred to the cancer center TCC workflow and 60 patients were eligible for a TCC appointment. 18 patients had appointments scheduled (30%) with 83% completed (15/18). 22% of scheduled appointments were via telemedicine (4/18) and 100% of these appointments were completed. Conclusions: TCM programs can be adapted to reward timely hospital followup for oncology patients after discharge. TCM requirements overlap with several common elements of readmission reduction initiatives, but EMR tools for identifying patients at highest readmission risk may need additional adaptation into clinic workflows to promote a high capture rate that justifies program support. Future longitudinal cohort analysis will establish if the TCC is able to reduce cancer-related readmissions in high-risk populations.