Care coordination and transition management (CCTM) is a new nursing specialty aimed at assisting patients while increasing quality, improving outcomes, and avoiding unnecessary healthcare utilization. CCTM departments have been developed and successes seen within these programs have had significant impacts on healthcare. Nurses are an essential part of these programs. At our NCI-designated cancer center, CCTM assists the achievement of internal and national goals. In an effort to provide seamless care across the continuum and enhance the patient experience, CCTM developed an unplanned readmission reduction program. Unplanned readmissions caused an estimated $528 million in Medicare penalties in 2017, increasing $106 million from 2016. Following high-risk patients during their cancer journey can not only help decrease unplanned readmissions but also help increase involvement in care, patient satisfaction, and perceived quality of care. By calling patients after hospital discharge, along with seeing the patients while at the facility, the nurse is able to assess patients using verbal and non-verbal cues as to how the patients are doing. This relationship can help identify any concerns, make sure follow-up appointments have been scheduled, that the patient has clinic contact information should a question arise or a problem develops before their next appointment, all while keeping the lines of communication open.
A data review was conducted to determine which group would most benefit from the introduction of such a program. It was found that the gastrointestinal (GI) oncology surgical patient population had one of the highest 30-day unplanned readmission rates throughout all groups admitted to the hospital. Two factors were found to potentially contribute to unplanned readmissions: lack of consistent education and lack of a post-hospital discharge phone call. A survey was used to poll the inpatient and clinic nurses in order to determine the educational topics that are commonly taught to all GI surgical patients and develop a standardized reference page given to all GI surgery patients. Post-hospital discharge phone calls took place within 48 hours of discharge. Prior to the implementation of this program, the GI surgical oncology program had an unplanned readmission rate of 13.4%. Three months after implementation this rate decreased dramatically to 5.9%. The unplanned readmission rate remains at approximately 8.3% (6.5% with an outlier removed) one year after implementation. The GI surgical oncology program has been used to expand the types of patients who receive phone calls. After this expansion, patients admitted to the internal hospital medicine (IHM) service and then discharged home without home health care, GU surgery patients going home without home health care, and any patient discharged home with a urinary diversion no matter their home health care status receive phone calls approximately 48 hours after discharge. Data is still being collected to determine how successful the expansion has been. We are continuing to work on improving our outcomes related to these patients and determine how to successfully expand the CCTM program to better serve other high-risk patients.