Navigating the Transition From Oncology Inpatient to Optimum Outpatient Care

A team of nurses is working to improve patient needs as they prepare to leave the hospital.

Easing the transition from inpatient to outpatient care is an ongoing challenge for oncology practitioners. Post-discharge care can be fragmented, and patients — many of whom are older with comorbidities — can be especially vulnerable when handed off back to their community providers and other specialist care after leaving their cancer center with a complex set of discharge instructions.

A team of nurses at Fox Chase Cancer Center sought to improve this process by optimizing care coordination with a more robust, multifaceted discharge planning process, and they are sharing their findings in a poster session at the 42nd Annual Oncology Nursing Society (ONS) Congress being held May 4-7 in Denver.

Theresa Pody, M.S.N., RN, NE-BC, explained in an interview with CURE that because Fox Chase draws from a broad geographic area, care transitions can be particularly challenging. When patients go back to their community, it may be quite a distance away: “We did find that was one of the challenges — maintaining those relationships during discharge planning so nothing fell through the cracks, which often happens in a multidisciplinary, complex patient care setting.”

To address this issue, Pody and colleagues initiated a system built around better communication and care coordination, and, importantly, an expanded role for an RN Transition Navigator to provide continuity between levels of care. Notably, the whole process — and the essential provider —patient discussions — starts early.

Every day at Fox Chase, teams involving physicians, nurses, case managers and sometimes social work and pharmacy, participate in multidisciplinary rounds. “We talk about the goals and plan for the day,” Pody said. “We also talk about when treatment will be completed, when the patient can go home, and if so, what needs to be set up. We also look at any medications that may need prior authorizations for, so the discharge isn’t delayed.”

This is where the elevated navigator role comes in. “We also created a discharge navigator role who is involved in the rounding, so he/she gets to know the patient up front and will make the follow-up phone call that will happen later.” The navigator, already well-versed on the case, usually makes the call 24 to 48 hours after discharge, and has a computerized transitions and care summary at hand to guide the discussion that has a snapshot of the patient’s records and experience while at the hospital.

In addition to patient-centered multidisciplinary rounds and the integration of the transition nurse navigator across the care continuum, Fox Chase developed an app to document all of the information communicated during the rounding process.

“We used to have paper forms of discharge instructions, covering everything,” Pody explained. “They’re now part of one computer application, with checkboxes and a problem list specific to the patient that nurses complete, so nothing is really missed. We don’t have to remember everything, it’s all right there.”

This document ultimately gets printed for the patient at discharge, along with a contact list with services provided at Fox Chase, emergency and outpatient clinic phone numbers, and a list of all services that could benefit the patient.

The patient leaves with those instructions and a schedule of follow-up appointments. A list of medications and side effects is attached that’s very helpful for the patient, Pody added. “Sometimes they have a list of medications as long as my arm.” A nurse at Fox Chase set up an app that lives on their internal nursing web page detailing the drugs and side effects, so it’s easy for nurses to access when the time comes.

Thus far, the program has been rated well in terms of patient satisfaction, as measured by answers to two custom questions the team added to the cancer center’s Press Ganey inpatient survey: one focused on the care coordination and transition process itself, and one about the follow up phone call.

Another goal was to limit the number of phone calls after discharge. Fox Chase has a triage line for patient questions, and the number of calls to that line has decreased in the surgical unit where the transition program was piloted.

Pody said that one of the toughest challenges when patients leave the hospital is making sure they go to the right point of care. “Sometimes they’re not strong enough to go home, even though they really want to. For us, to prevent them from coming back again, it’s about making sure that the next level of care post-discharge is appropriate for them.”

Here again, she said, having a discharge navigator helps to identify if the patient needs transition to a different level of care, to a rehab facility, for example, or needs support at home.