Introduction: A high outpatient clinic no-show rate affects clinical outcomes, increases healthcare costs, and reduces both access to care and provider productivity. In an effort to reduce the no-show rate at a busy palliative medicine outpatient clinic, a quality improvement project was launched consisting of a telephone call made by clinic staff prior to appointments. The study aimed to determine the effect of this intervention on the no-show rate, and assess the financial impact of a decreased no-show rate. Methods and Materials: The outpatient clinic no-show rate was measured from September 1 to December 31, 2015. Data from the first 8 months of the calendar year was removed since these could not be verified. Starting January 1, 2016, patients received a telephone call reminder 24 hours prior to their scheduled outpatient appointment for confirmation. No-show rate was again measured for the calendar year 2016. Opportunity costs were calculated for unfulfilled clinic visits. Results: Of the 1224 completed visits from September 1 to December 31, 2015, 271 were no-shows with an average rate of 11.8%. After the intervention, there were 4368 completed visits and 562 no-shows. The no-show rate for 2016 averaged 6.9% (p < 0.001), down 4.9% from the last 4 months of 2015. Estimated opportunity costs were about 396 no-show visits avoided, equivalent to an annual savings of about $79,200. Conclusion: A telephone call reminder to patients 24 hours prior to their appointment decreased the no-show rate in an outpatient palliative medicine clinic. Avoiding unfulfilled visits resulted in substantial opportunity costs.

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143 Background: The Oncology Care Model (OCM) is a novel 5-year quality-based Oncology payment and care delivery program established by the Centers for Medicare & Medicaid Service in 2016. OCM prioritizes high-quality, coordinated care for patients undergoing chemotherapy (chemo pts.) Participating centers provide augmented services to enhance care and meet quality goals. Challenging symptoms (sxs) are common among chemo pts and may lead to hospitalization and decreased quality of life. Specialist palliative care teams are not able to see all chemo pts with active sxs. Front line oncology care teams (FLC) need education on primary palliative sx management. Methods: Cleveland Clinic Taussig Cancer Institute is one of 181 practices voluntarily participating in OCM. Locations include main campus and 5 regional cancer offices with 100 oncologists caring for about 4,000 chemotherapy patients annually. Our OCM team engaged Oncology (Onc) and Palliative Medicine (PM) providers to standardize sx management. Education was provided to FLC of all disciplines. Electronic record analytics were used to determine emergency department (ED) utilization. Results: A multidisciplinary team of Onc and PM experts developed guidelines for 4 common sxs (chemotherapy-induced neuropathy, persistent cancer pain, nausea/vomiting and constipation. Guidelines were approved by key Onc and PM staff and made available to all providers online. There were 4 educational sessions for FLCs to all sites in 2017. Urgent sx outpatient appointment slots were created in oncology offices to address uncontrolled sx. From Dec 2017 to May 2018, ED visits for all cancer patients at main campus decreased from 500/month to 453/month (9.4%.) Reductions in ED visits were also seen at 2 hospitals adjacent to regional cancer centers (16% and 6%.) Conclusions: OCM participation provided an opportunity to improve care quality at our institution. Primary palliative sx guidelines were successfully developed by an interdisciplinary team and disseminated to FLC. Urgent sx management appointments were made available in oncology offices. These interventions coincided with a reduction in ED visits for all cancer patients.

80 Background: Reducing length of stay (LOS) is an important initiative for hospitals for both clinical and financial reasons. Patients who are hospitalized for extended lengths of time may be more susceptible to hospital-acquired infections and other complications. Reducing LOS can also decrease cost of care and allow for more streamlined patient throughput. Our institution sought to evaluate opportunities to reduce LOS for our medical oncology patient population. Methods: Several interventions were implemented to streamline discharge planning. The structure of rounding was evaluated and standardized on each inpatient oncology unit to ensure that it was multidisciplinary and occurred each day at an established time. A process was established for Advanced Practice Providers (APPs) to write prescriptions the day before discharge (delivered directly to the bedside), and for APPs to begin discharge of patients early the following morning with use of a new discharge checklist. Standardized workflow was also created for instances where prior authorizations were required for prescriptions. We partnered with our Home Care providers to streamline the process for patients anticipated to be discharged to that service. Partnership was also established with physical therapy (PT) to avoid ordering low-value consults and to provide enhanced education to nursing staff about early patient mobility. Another project is being piloted to move lab draws six hours earlier the night prior to discharge. This provides the medical team additional time to assess and treat based on lab results if the patient required blood product transfusions or electrolyte replacement prior to discharge. Results: Implementation of interventions began throughout the first several months of 2019. Each of the first four months of 2019 saw consecutive improvements in both observed average LOS and LOS observed-to-expected ratios. Overall, a 2% decrease was seen in both of these metrics when comparing January to April 2019 to the 2018 baseline. Conclusions: Implementing several interventions to streamline workflows and processes leading up to a patient’s discharge can be effective in reducing both overall LOS and LOS observed-to-expected ratios.

Palliative care has changed since its inception with Dr Balfour Mount in 1976. It is moving slowly from the care of the dying (which is still an important part of palliative care) and crisis intervention to integrated care with oncology early in the course of advanced cancer. Several studies have demonstrated the advantages to this approach. In this review we will discuss indicators of structure process and outcomes, outcomes to integration, components to successful integration of care and barriers to integrated care. Family financial toxicity related to cancer care is a growing problem that will need to be measured as an outcome to integrated care ARTICLE HISTORY