171 Background: Due to complexity of disease and treatments, oncology patients have among the highest hospitalization rate, especially towards End of Life (EOL). In our cancer institute, just 6% of all discharged patients accounted for >40% of unplanned readmissions, and continue to be highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and under use of hospice care. We hypothesized that developing individualized care plans (ICP) for this high-utilization group will provide guidance in the complex care they require to reduce unnecessary and aggressive medical services. Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, and nurses. On a bimonthly basis, patients with at least two unplanned hospital readmissions over the last 60 days were identified. ICPs were created using a team-based approach with parallel input from patient’s primary outpatient providers. Results: A total of 36 patients, 226 hospitalizations, and 163 ED visits were evaluated over a 6-month period, with an average number of hospitalizations of 1.08 per patient month (ppm). After implementation of ICP, hospitalizations decreased to 0.23 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days. Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay. A dedicated focus from a team of experts, beyond disease biology, on a unique patient situation may result in improved patient experience with decreased aggressiveness of care at EOL and overall resource utilization.
145: Rethinking the cystic fibrosis care team: A novel telehealth structure promotes interdisciplinary care and improves understanding of team member roles
