Bridging the Gap: Achieving Excellence in Oncology Transitional Care

Abstract

Transitional care (TC) is the provision of care coordination for at-risk populations aimed at improving continuity and overall patient outcomes. The purpose of the DNP project was to utilize the evidence-based Transitional Care Model (TCM) to facilitate care transitions by oncology nurse navigators and social workers. The project's goals were to increase transitional care visits provided to lung cancer patients by navigators and improve patient satisfaction for patients experiencing transitions in care. The model included identifying high-risk cancer patients using risk stratification tools and the delivery of timed interventions for following patients from their hospital stay to an outpatient setting. Primarily, the team was responsible for complex care coordination, including the identification of barriers that precluded patient success with treatment. By ensuring that care was coordinated effectively, patients were actively engaged in their care, resulting in improved patient satisfaction. Additional benefits included reducing hospital readmissions and improved team productivity. Future work includes incorporating the new process for the entire navigation team at the organization and examining the impact of the ongoing process on outcomes.