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Coordination of Care/Care Transitions

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.
The moment a patient is diagnosed with cancer their entire world changes; cancer is not the same for any patient.
Baylor Scott and White McClinton Cancer Center (BSWMCC) is a comprehensive community cancer center located in Central Texas offering medical and radiation oncology services, plastic and reconstructive surgery, and lymphedema therapy, with approximately 275 patient encounters daily.
The oncology nurse navigators (ONNs) at Lehigh Valley Health Network-Cancer Institute, comprising 8 oncology-certified registered nurses, were presented with an initiative from the administration to assist with preventing patient readmissions due to severe toxicities that could otherwise be managed in the outpatient setting.
There are approximately 436,060 head and neck cancer (HNC) survivors living in the United States, and long-term survival is becoming more common in this population.
Oncology navigation is evidence-based and plays an important role in lung cancer care, but variation remains in the navigator’s role across the continuum from early- to late-stage lung cancer.
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.
Head and neck cancers (HNCs) include a heterogeneous group of cancers.
To address the inequities that underserved populations often face during their cancer experience, the Wake Forest Baptist Comprehensive Cancer Center developed a novel nonclinical navigation program for African American (AA), Hispanic, and rural cancer patients.
Our organization had the opportunity to reduce the time of discovery of suspicious mass to surgeon consultation for patients with rectal, esophageal, and pancreatic cancer.
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