Bridging the Gap: Achieving Excellence in Oncology Transitional Care

November 2021 Vol 12, No 11
Chelsea Passwater, DNP, APRN, AGCNS-BC, OCN
Clinical Associate Professor
East Carolina University
Greenville, NC

Background: Transitional care (TC) is a series of interventions aimed at improving outcomes for patients who are experiencing a change in care status, such as hospital to home.1,2 Lack of communication, collaboration, and discontinuity of care contribute to poor outcomes for patients undergoing a transition. Incorporating TC before and after discharge can be used to meet patient needs, reduce hospital readmissions, and increase patient satisfaction.1,3 Using the evidence-based Transitional Care Model (TCM), coordination of care is delivered at timed intervals by nurses, starting before the patient leaves the hospital and continuing after the patient returns home. During a combination of telephone calls and/or face-to-face visits, patients are asked questions about medications, symptoms/signs, and appointments as well as assessed for any barriers to treatment compliance.

Objectives: To implement the evidence-based TCM within the oncology setting delivered by navigators. Applying the TCM will provide opportunities for early identification of patient needs and increase interdisciplinary communication. The goals are to increase navigator productivity, and to improve satisfaction for patients experiencing transitions in care. The overall goal is for patients to overcome barriers to care to help keep them out of the hospital and to remain successful with oncology treatment.

Methods: Oncology navigators were trained in TC, including how to identify and follow high-risk patients. Over a 12-week period, navigators completed daily chart reviews of inpatients on the medical oncology unit to identify high-risk patients. Patients were assigned a risk score based on factors including number of hospitalizations, comorbidities, and social determinants of health using the Inpatient Readmission Risk Assessment Tool embedded within the electronic health record. All patients with a score of 3 or higher were deemed high-risk and were followed by the navigators at planned intervals to provide coordination of care. Navigators met with patients prior to hospital discharge and followed them at a minimum of 7, 14, and 21 days after discharge.

Results: Sixty-two patients received TC services. In the month prior to project implementation, there were 103 total encounters with 68 (66%) Coordination of Care visits (COC-V) and 76 (74%) Patient Education visits (PE-V), improving to 142 total encounters with 126 (89%) COC-V and 132 (93%) PE-V. Throughout implementation, there were 6 (9.6%) 30-day readmissions, which was lower than the national average of 27% for oncology patients. Prior to implementation, the inpatient medical oncology unit was underperforming the benchmark in 2 of 3 patient satisfaction questions related to TC but improved to outperforming the national benchmark for the majority of all measured points during the project implementation period.

Conclusions: The TCM was successfully implemented. Improving navigator productivity allowed for a streamlined workflow in identifying and coordinating care for patients. Interventions delivered by navigators improved patient satisfaction. The low rate of 30-day hospital readmissions indicated that navigator services were effective in keeping patients out of the hospital. Furthermore, the project improved interdisciplinary communication and coordination of care, which translates into improved overall outcomes for patients.


  1. Naylor MD, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.
  2. Hirschman KB, Shaid E, McCaulty K, et al. Continuity of care: the Transitional Care Model. The Online Journal of Issues in Nursing. 2015.
  3. Naylor MD, Hirschman KB, Toles MP, et al. Adaptations of the evidence-based Transitional Care Model in the U.S. Soc Sci Med. 2018;213:28-36.
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Last modified: August 10, 2023

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