Additional Project Information
The ToCPP is sponsored by the Chief Allied Health Officer, Clinical Excellence Queensland.
A project oversight committee, consisting of key stakeholder representatives, provides guidance and endorsement relating to the development and implementation of the project model of care.
A ToCPP project officer was appointed to facilitate project scoping, design, implementation and evaluation.
Model of care
The project model of care has been endorsed by the ToCPP oversight committee following consultation with stakeholders.
Patient risk assessment
The ToCPP model of care is dependent on the patient’s risk of readmission. Risk will be determined using the LACE index for readmission.
THE LACE index predicts patient risk of readmission or death within 30 days of discharge from medical and surgical wards. The tool has been validated in several studies.,
Risk of readmission is calculated as a score from 1– 19 based on the following criteria:
- Length of stay
- Acuity of admission (acute or elective)
- Charlson Co-morbidity index
- Number of Emergency presentations within the previous 6 months (not including the current admission)
Risk is attributed as follows:
- High risk: ≥ 10 points
- Moderate risk: 5-9 points
- Low risk: 1-4 points
Online calculators are available for clinicians to calculate the LACE score : https://www.mdcalc.com/lace-index-readmission
Note: patients who are LACE classified as having a low or moderate risk of readmission can be managed under the high risk pathway in the following circumstances:
- Treating team referral for post-discharge follow-up
- Identified risk of medicine misadventure
 van Walraven C, Dhalla IA, Bell C, Etchells E, Stiell IG, Zarnke K, et al. Derivation and validation of an index to predict early death or unplanned readmission after discharge from hospital to the community. CMAJ. 2010;182(6):551-7
 Shaffer BK, Cui Y, Wanderer JP. Validation of the LACE readmission and mortality prediction model in a large surgical cohort: Comparison of performance at preoperative assessment and discharge time points. J Clin Anesth. 2019;58:22-6.
 Gruneir A, Dhalla IA, van Walraven C, Fischer HD, Camacho X, Rochon PA, et al. Unplanned readmissions after hospital discharge among patients identified as being at high risk for readmission using a validated predictive algorithm. Open medicine : a peer-reviewed, independent, open-access journal. 2011;5(2):e104-e11.
 MD+ CALC. LACE Index for Readmission [Internet]. MDCalc. Available from: https://www.mdcalc.com/lace-index-readmission
- A service evaluation will be undertaken with service providers and users to determine perceptions, service benefits, sustainability, and the facilitators and barriers to implementation.
- An economic evaluation will be undertaken to determine the economic impact of the service.