Introduction

One-fifth of Medicare patients are readmitted to the hospital. The readmission rate among liver transplant recipients at a large tertiary academic medical center in 2015 was 30%. We hypothesize that using the LACE index tool, we could identify patients who would benefit from a Transitional Care Coordination (TCC) program focused on clinic attendance, lab-work compliance, medication management, and patient education.

Methods

The LACE Index on the day of hospital discharge was used to screen 36 patients who received a liver transplant and were discharged between February and March 2016. Twenty-five patients were deemed high risk for hospital readmission ( LACE > 10) and referred to the TCC. Seven patients did not meet TCC eligibility and were not referred. Four patients could not be evaluated due to complications. The effectiveness of the TCC was measured by retrospectively comparing the readmission rates from February thru March 2015 in a matched-control group.

Results

A total of 41 patients were eligible for the TCC program (16 in 2015; 25 in 2016). 5/25 (20%) were readmitted within 30 days of discharge. Comparatively, readmission rates within the control group was 37.5%(Pearson's chi-square p = 0.01), suggesting that the TCC program was effective at preventing readmissions.

Conclusions

The LACE Index is able to predict at-risk patients for readmissions and is a valuable asset to liver transplant programs. A TCC program can significantly reduce 30-day readmissions. Future studies will focus on readmission rates at 60 and 90 days post-discharge and the affect of TCC on long-term outcomes.

CITATION INFORMATION: Masoumi A, Krzyzewski J, Stern T, Schluterman N, Bruno D, Bromberg J, Barth R, Hanish S. Screening and Referral of High Risk Liver Transplant Recipients to a Transitional Care Coordination (TCC) Program to Reduce Hospital Readmissions. Am J Transplant. 2017;17 (suppl 3).

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