Implementation Of An Interdisciplinary Care Team To Create Individualized Care Plans For High Risk Oncology Patients: A Model To Decrease Aggressiveness Of Care At The End Of Life And Improve Cost Effectiveness Of Care.

171Background: 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 u003e40% 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...