Initial Patient Assessment and LACE

The LACE is a popular tool 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. Case management leaders looking for ways to determine how to identify patients at “high risk” for progression of care obstacles use the LACE to stratify patients for case management referral.

At the time of their hospital admission, every patient is assessed by a professional nurse.  The assessment is a systematic method by which the patient's nurse plans and provides care for patients. This involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs and to plan, deliver, and evaluate nursing care in an orderly, scientific manner.  It is meant to evaluate the patient’s health status, to identify functional health patterns that are problematic, and to provide a base-line to use to evaluate changes in the client’s health status over the course of treatment. 

The EMR screens for the initial patient assessment typically includes an assessment of physical status including medical / surgical history, current medications, pain and nutritional screening, fall risk assessment, family history and support system, self-care deficits and a functional assessment (ADL).  In addition, patient is assessed for a history of psychosocial or addiction problems within the family, current drug and alcohol usage of other members of the family or household, interpersonal relationships, and pertinent emotional, behavioral or spiritual health issues.

In total, the assessment provides a comprehensive overview of the patients' status that informs the nurse and the care team of the patients' current needs and possible risks, and offers the care team the opportunity to make referrals to additional services such as nutrition, wound care, infection control, care management, or psychosocial counseling.

Oftentimes, the database of information that this assessment provides plus the insights from other members of the care team is enough to also identify the patients' risk to progression of care obstacles, excessive resource utilization, transition delays, and risk of readmission. Of late, with broader data integration, these initial patient assessments may incorporate parameters that are even more specific to these risks such as polypharmacy, comorbidities, the number of physicians seen in the last 6 months, or the volume of ED visits an d past hospitalizations.   When the hospital has an EMR, and integrated data system, a data warehouse and active data governance program to 'clean' the data from multiple sources, those parameters can easily become part of the initial assessment and can be used to determine whether the patient is high risk and warrants a referral to a case manager.

In the absence of a comprehensive initial patient assessment, many hospitals are using LACE. 

LACE is a index scoring tool to identify patients at risk for readmission or death within 30 days of discharge.  The LACE index comprises four parameters:  length of stay. type of admission (acuity), comorbidities using the Charlson Comorbidity Index, and number of ED visits.  A patient's LACE score (risk for readmission) ranges from 1 to 19;  the higher the score, the most at risk a patient is.  In more tech-savvy facilities, patient data is automatically pulled from the EMR to make the LACE calculation and we've been told that in several hospitals, LACE is incorporated into the initial patient assessment to streamline the entire assessment process requiring less resources. 

Predictive analytics are quickly becoming a necessary component of a enterprise wide population health strategy and LACE is often the first step to identify high risk patients who warrant assertive advocacy and focused care coordination.