ORLANDO, FL—The oncology triage nurse has the potential to improve patient outcomes along the continuum of care when serving as a pivotal conduit with acute care hospitalists and medical oncology, a study presented at the ONS 40th Annual Congress concluded.

In 2013, the Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) called for transitional care management (TCM) services to improve patient outcomes after discharge.

Effective TCM can reduce medication errors, better manage patients with complex comorbidities, improve dissatisfaction with quality of care, and reduce high rates of preventable readmissions and the high human and financial cost burden. 

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Medicare reports 18% of patients are rehospitalized within 30 days, 34% within 90 days, and 13% experience more than three provider transfer within 30 days at a cost of $26 billion.

Fox Chase initiated a Transitional Care Clinic (TCC) in an ambulatory oncology department. Its goal was to prevent readmission within 30 days of discharge from hospital and improve patient outcomes, explained Jean Smith, RN, OCN®, Fox Chase Cancer Center, Philadelphia, Pennsylvania.

The ambulatory oncology triage nurse is responsible for initiating contact with the patient and/or caregiver via a telephonic visit within 48 hours of discharge, explained Smith.

During this interview, the telephone assessed discharge status is compared with the discharge summary and medication reconciliation form completed by the hospitalist and medical oncologist.

In addition to the transitional telephonic visit, an on-site TCC visit is conducted within 2 weeks of the patient being discharged. High complexity cases are seen on site within 1 week.

“The initial call documents subjective patient responses regarding health status, medication review, and teaching, as well as instructions for follow-up appointments. The visit can then be moved up if needed, based on the the patient’s responses,” she said.

“Sometimes labs, IV hydration, or other interventions are needed that can be done in the outpatient setting, thus thwarting readmission.”

The on-site visit assessment is performed by the nurse, followed by the hospitalist who cared for the patient. The hospitalist finalizes the visit note, which is sent to the patient’s primary care physician with the medication reconciliation and discharge summary.

The cancer center is currently collecting Transitional Care Clinic outcomes data, including compliance, rate of readmissions, and overall patient satisfaction.

Additional transitional care services in development include mobile medication and symptoms support, diagnosis-specific management, including caregivers in the transitional  care team, and health care tips and wellness texts.