Navigating Care Transitions to Improve Efficiency from an Inpatient Cancer Diagnosis to the Outpatient Treatment Setting

Background: Integrated care is an approach for improving care transitions, but identifying patients to benefit from the assistance of an oncology nurse navigator (ONN) is inconsistent or nonexistent for patients transitioning from an acute inpatient setting to an outpatient treatment area. People with complex medical conditions, such as a cancer diagnosis, are vulnerable during care transitions and experience delays. Baseline data show the current identification process fails to connect the ONN to the patient while in the hospital. On average, the ONN first meets the patient in the outpatient care setting 39 days after the diagnosis. Without the aid of navigation, the patient waits an average of 12 days for the first outpatient connection to an oncologist. Furthermore, the delay causes outmigration to the competitor’s services with earlier appointments.

Objectives: (1) To implement a transitional care program for hospitalized patients using an electronic medical record (EMR) to notify the nurse navigator, (2) have the navigator connect with the patient within 72 hours of referral, (3) have the ONN transition the patient timely to oncology, (4) disseminate the e-referral change process to inpatient staff using standardized e-learning and in-services, and (5) increase interprofessional collaboration and communication.

Methods: The quasi-experimental study used innovation to identify the population of newly diagnosed cancer patients within 72 hours of receiving a new cancer diagnosis in the acute inpatient care setting. The team of 3 outpatient ONNs led the study, which includes nurse leaders and various inpatient staff. Using the current EMR, an e-referral process was developed and implemented for nurses, providers, and ancillary staff. The project focused on 3 benchmarks: (1) ≤11 days from diagnosis to first contact with a navigator, (2) 30 days from diagnosis to first medical oncology visit, and (3) determine if e-referrals are the most effective referral method. Inpatient units received an in-service on the new process. An online module was developed to measure staff understanding and competency. To evaluate the implementation, we merged quantitative measures on the timing and type of referral, time to navigation, and oncology setting.

Results: The intervention measured 246 referrals during 6 months, with 55 received by the e-referral process. The e-referrals reduced the time from diagnoses to ONN to 3 days (92% reduction), with the navigator connecting to the patient in less than 24 hours of receiving the notice. When the e-referral was compared with alternate identification methods, such as ONN review of pathology or providers’ new patient schedule (25 days), MD/App referrals (27 days), or support staff referral (5 days), it proved to be the best method to connect to the patient. Furthermore, ongoing data collection shows a reduction in the time to an oncology appointment (4 days).

Conclusions: Using innovative technology to implement an e-referral process for staff is a method to identify patients earlier, allowing the navigator to connect with the patient and distinguish obstacles in care transition. Early referrals identified unmet needs and provided the patient with timely seamless coordination of care to in-system oncology.