One-fifth of Medicare patients are readmitted to the hospital an annual cost of $17.4 billion. The readmission rate among liver transplant patient populations at a large tertiary academic medical center in 2015 was 30%. Hospital readmissions are responsible for a cost over $656 million each year. The LACE Index is a validated scoring tool for predicting patients that are at high-risk for hospital readmission within 30 days of discharge.

Thirty-six patients who received a liver transplant or were discharged in an 8-week screening period during the months of February and March 2016, from a 27 bed Intermediate Care (IMC) Abdominal Transplant unit were included. Twenty-five patients were deemed high risk for hospital readmission based upon the LACE Index Scoring Tool and were referred to the associated TCC program. The effectiveness of the referral process and TCC program were measured by comparing the readmission rates from February and March 2015, and after the TCC program intervention. Four Patients with potential for a high LACE score were not able to be evaluated due to complications associated with patient specific co-morbidities and inpatient mortality. In total, 25 patients were referred to and completed the TCC program.

The TCC referral and screening process was 100%. Between the retrospective 2015 data and 2016 data, a total of forty-one patients were eligible for the TCC program (16 patients in 2015 and 25 patients in 2016). All patients who received care through the TCC program were seen between February and July, 2016. Among the 25 patients referred to the TCC program in 2016, 5 (20%) were readmitted within 30 days of hospital discharge. The retrospective 2015 data showed a readmission rate of 37.5% of those who would have been eligible for, but did not receive the resource of the TCC program. The was a significant difference in readmission proportions between equally eligible patients who did and did not receive the TCC program and those who did (Pearson's chi-square p=0.01

The LACE Index Scoring Tool may be a valuable asset to liver transplant programs for identifying patients who are at high-risk for readmission within the first 30 days of hospital discharge. Additionally, these identified patients are predicted to benefit from intense post-discharge care through programs such as the TCC.

CITATION INFORMATION: Masoumi A., Barth R., Stern T., Bruno D., LaMattina J., Hanish S. Reducing Hospital Readmissions: Referral of High Risk Liver Transplant Patients to a Transitional Care Coordination(TCC) Program Am J Transplant. 2017;17 (suppl 3).

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