Implementing LACE Assessment to Identify “High Risk” Patients and Target Interventions
Achieved and maintained the goal of providing at least 95 percent of HF patients with all the recommended procedures and assessments in the Measure of Ideal Care bundle for 13 out of 15 months during the initiative.
Redington-Fairview General Hospital
46 Fairview Avenue
Skowhegan, Maine 04976
Redington-Fairview General Hospital is a 25-bed critical access independent community facility that provides health care for more than 30,000 residents living in rural Somerset County, bordering the Canadian border.
Janet McCollor, R.N.
Community Case Management
P: (207) 858-8394
Participating in a webinar about finding patient trends to reduce readmissions prompted the team at Redington-Fairview General Hospital to look at its current data to identify common trends that could be used to improve its 30-day readmission rate following heart failure hospitalizations.
The hospital formed a planning team, consisting of nurses and other frontline staff, to determine how to identify patients at “high risk” for being readmitted. The team choose the “LACE” assessment – a popular tool used at other hospitals that calculates a readmission risk score based on length of stay, acute admission through the emergency department (ED), comorbidities and emergency department visits in the past six months.
The hospital team tested the effectiveness of the system for 18 months. Upon each admission, patients were assigned a LACE score – the higher the score the higher the risk for readmission. Determination of a high LACE score prompted hospital staff to conduct additional risk screening tests as well as enhance patient education and telephonic monitoring conducted by a member of care transition team.
The hospital team credits the use of the LACE tool for helping to reduce its 30-day readmissions rate following heart failure hospitalizations by almost 7 percent. The hospital team is in the process of expanding the implementation of the modified LACE tool and enhanced discharge plan to community stakeholders such as area home health, social service workers, hospital and community care managers.
Promising Practices on Care Coordination & Readmissions
Poor care coordination contributes to the issue of avoidable readmissions.Learn more