Implementation Of Individualized Care Plans In High Risk Oncology Patients: A Team Based Model To Decrease Unnecessary Utilization

6547 Background: Due to complexity of disease and treatments, oncology patients (pts) have among the highest hospitalization rate. In our cancer institute, just 6% of all discharged pts accounted for > 40% of all unplanned readmissions (UR), and continue to be of highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and underutilization of hospice resources. We hypothesized that developing individualized care plans (ICP) will better provide the complex care necessitated by this group Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians/social workers/care coordinators/nurse managers. Twice monthly, pts with the highest utilization over a 60-day period with at least two UR were identified. ICPs were created using the team-based approach with parallel input from primary outpatient providers. Communication plans were created to ED and outpatient teams Results: A total of 71 pts, 356 hospitalizations, and 260 ED visits were evaluated over a 6-month period, with an avg number of hospitalizations of 0.82 per pt month (ppm). After creation ICT, this decreased to 0.23 ppm. Average ED visits, UR, avg length of stay per admission also decreased (see Table 1). Nearly all solid tumor pts had metastatic disease at ICT review, while pts with hematological malignancies were early in their treatment course receiving myelosuppressive therapy. These results were compared to a historical cohort prior to ICT with the same inclusion criteria, which maintained to show a high relative impact Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay in all disease groups, but ST patients seemed to have a greater impact than in HM patients Effect of ICP. All Patients N = 71 Solid Tumor N = 40 Malignant Hematology N = 31 Hospitalizations Before ICP 0.82 0.79 0.89 After ICP 0.36 0.27 0.49 30-day Readmissions Before ICP 0.49 0.48 0.51 After ICP 0.13 0.05 0.29 ED Visits Before ICP 0.60 0.61 0.57 After ICP 0.24 0.18 0.42 Average LOS per Admission Before ICP 7.17 6.24 8.48 After ICP 4.06 2.55 6.17