Equity-Enhanced Discharge
Reducing racial disparities in cancer readmissions
In collaboration with UChicago Medicine Cancer Center
Kim Erwin
Associate Professor of Healthcare Design and Design Methods, Director, Equitable Healthcare Lab
Meghna Prakash
Assistant Director, Equitable Healthcare Lab
Emery Donovan
Master of Design, 2023
Abigail Irvine
Director, Quality and Network Integration at UChicago Medicine
Mary Morgan
Master of Design Methods, 2023
Pascale Frederique
Program Manager - Cancer Service Line at UChicago Medicine
Smrti Ganesan
Master of Design, 2023
Blase Polite, MD
Executive Medical Director for Cancer Accountable Care, Medical Oncologist at UChicago Medicine
Janhavi Singh
Master of Design, 2024
CHALLENGE
How might we reduce racial disparities in cancer readmissions?
Data analysis suggests that patients of color are 1.5x more likely to readmit after a hospitalization for cancer treatment than White patients. How could UChicago Medicine improve its services to better meet the needs of this patient population?
“To make progress, we need to move from characteristics of the patient — race, gender — to characteristics of the system: racism, patriarchy. The problem is not the patients. They are the result of an unequal system.”
APPROACH
We applied a mixed methods approach to explore the opportunity space. We analyzed 12 months of readmissions data to identify more precisely we should be talking with. We looked at age, zip code, insurance and other factors. We then engaged 20 patients and caregivers in bedside or infusion bay interviews and used card sorts to identify their priorities for follow-up care.
We also observed inpatient work processes, such as Multidisciplinary Rounds (MDRs) and spoke with 21 floor nurses, hospitalists, outpatient oncology nurses, patient navigation coordinators, community health workers, social workers and a home health nurse to learn from their experiences.
SOLUTIONS
Equity-Enhanced Discharge is a proposed tailoring strategy for discharging patients who are not well-served by standard discharge practices: individuals who 55 years or older, reside in the 6 zip codes immediately surrounding the hospital, and self-identify as Black or mixed race. We also identified “enabling” solutions to improve the overall efficiency of discharge and better prepare patients of color and their families for the transition home.
1. Prioritized for Meds-2-Beds (M2B): Medication access and use is critical to staying out of the hospital, say participants. Yet these patients were less likely to receive an evidence-based program called Meds-2-Beds. M2B makes sure patients go home with all their prescriptions. It also enlists a pharmacist to explain how and when to take medications. Equity-enhanced discharge will automatically enroll at-risk patients, who are more likely to live in pharmacy deserts, in M2B.
2. Patient self-assessment for discharge: Many patients don’t understand or agree with the support they will need after discharge. Many patients turn down services, assuming their caregivers can do it all. The patient readiness for discharge tool asks patients 8 questions related to success at home: stamina, information, coping ability and home support. Incorporating this tool into discharge puts the patient’s voice into the planning process. It also sets a context for discussing critical follow-up services, such as home nursing, to improve patient uptake and engagement.
3. Discharge checklist: More than 6 disciplines are involved in discharging patients from the hospital. The lack of real-time, accurate information about status of various discharge activities and who’s doing them takes time away from patient care and keeps patients sitting in beds when they could be heading home. Hard-to-use documentation and unclear accountability for scheduling services also disrupts critical follow-up care. A robust discharge checklist would improve team coordination, efficiency, and patient engagement.
4. Bedside coordinator: Patients and families are often confused by and even disagree with follow-up care plans. This results in missed appointments and poor use of home services. The bedside coordinator is knowledgeable in both the home context and cancer care. They provide a face-to-face consultation that engages patients and caregivers to define follow-up appointments to ensure the plan is realistic.
OUTCOME
Pilot testing with the cancer service line is starting in Summer 2024. We conducted 2 multidisciplinary co-design sessions to build the discharge checklist and a workflow to incorporate the patient readiness for discharge tool. A pilot test of all 4 interventions using a stepped roll-out begins in late summer.
