Table 1.

Transitional care bundle and interventions based on LACE risk stratification score

Bundle element	Risk (LACE score)
	Low (0–6)	Medium (7–10)	High (11–19)
KPNW bundle elements
Risk stratification	X	X	X
Standardized discharge summary	X	X	X
Medication reconciliation	X	X	X
Transition hotline	X	X	X
Posthospital visit with physician		≤ 14 days	≤ 7 days
Phone call ≤ 72 hours after discharge			X
KPSC new bundle elements
Palliative care consult (if indicated)			LACE ≥ 15
Complex-case conference			X

KPNW = Kaiser Permanente Northwest; KPSC = Kaiser Permanente Southern California; LACE = Length of stay, Acuity of admission, Comorbidities, and Emergency room visits in last 6 months; X = indication to implement bundle element.