Bridging the Gap: Achieving Excellence in Oncology Transitional Care

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.D.N.P

Exploring behaviors, treatment beliefs, and barriers to oral chemotherapy adherence among adult leukemia patients in a rural outpatient setting

Objective: Adherence to oral chemotherapy is essential for patients with chronic myeloid leukemia (CML) and multiple myeloma (MM) to remain in remission. Few studies have used a Likert-type scale to measure medication adherence in CML and MM patients. We applied a validated treatment adherence tool, the ASK-12 (Adherence Starts with Knowledge®) survey, which assessed inconvenience and forgetfulness, treatment beliefs, and medication-taking behaviors recorded on a five-point Likert-type scale at two visits. Results: A medication adherence survey was administered to 42 newly diagnosed or pre-existing CML or MM patients at two outpatient oncology clinics affiliated with an academic medical center in rural eastern North Carolina. Thirty-one patients completed surveys at visit 1 and visit 2 (median 4.5 months apart). Most patients were treated for MM (65%), were non-Hispanic black (68%) and female (58%). Within subscales, mean adherence scores decreased between visits, signaling better adherence. Overall, visit scores were correlated (0.63, p = 0.001). Forgetting to take medication sometimes was the most common reason for non-adherence. Medication costs were not a barrier for MM patients. Greater patient–provider informed decision-making was identified as an opportunity for quality improvement among CML patients. The ASK-12 survey provided a strategy to obtain robust information on medication adherence

Bridging the Gap: Achieving Excellence in Oncology Transitional Care

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