How might we reduce racial disparities
in unplanned cancer readmissions?
In collaboration with UChicago Medicine Cancer Center​
TEAM​
Kim Erwin, Director, Equitable Healthcare Lab
Emery Donovan, MDes 2023
Smrti Ganesan, MDes 2023
Mary Morgan, MDM 2023
Janhavi Singh, MDes 2023
SECTOR​
Healthcare: Quality Improvement
DURATION​
August 2023 – present
ROLE
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Design Research, Project Management
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Challenge
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?
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.
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We engaged 20 patients and caregivers in bedside interviews and card sorts to identify their priorities for follow-up care; and 21 healthcare staff in interviews and intercepts.
Stakeholder perception map: diverse stakeholder groups involved with patient care and their respective (sometimes competing) priorities.
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.
4-pronged Intervention Strategy for
Equity-Enhanced Discharge
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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.
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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.
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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 & 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 & unclear accountability for scheduling services also disrupts critical follow-up care. A robust discharge checklist would improve coordination, efficiency, and patient engagement.
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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 began 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 has begun, with the Meds2Beds pilot currently underway. There are 9 eligible patients currently enrolled in Meds2Beds, being tracked for impact of enrollment on unplanned readmissions.
Phased pilot plan underway, the first one being Meds2Beds prioritization (top left), followed by Discharge Checklist (top right) and finally the Patient Readiness Self-Assessment (bottom right)
Reflection
This was my first experience of working on a healthcare service design project, which led to a lot of learnings about designing for a complex system such as healthcare:
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Start by understanding the constraints and possibilities of the system: map the current state and conduct a literature review of how this problem has been solved in other health systems.
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Conducting data analysis to narrow down the affected patient population and who needs to be interviewed to understand the impact of the problem at hand.
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The more we involve floor staff, such as Floor Nurses, Patient Navigation Coordinators and Care Coordination, the easier getting stakeholders on-board for implementation was, since they had buy-in into the concept and proposals.
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Moving forward with implementation with multi-disciplinary stakeholder engagement is critical and one of human-centered design's strengths. This, however, entails checking with each stakeholder at every point, and that inevitably leads to a slower pace of progression.