Case Study: Fox Chase Cancer Center 2019 HAP Achievement Award
Awarded for: Optimizing Care Transitions: Reimagining Case Management
The goal: Improve patient and staff satisfaction and reduce readmission rates by redefining roles and responsibilities related to discharge planning and care transitions and piloting a new role: the transitional care nurse navigator.
To develop and implement this new role, Fox Chase:
- Conducted an analysis of current and new roles, responsibilities, and budgets
- Restructured the existing case management, utilization review, and social services departments, using social services in a more consultative role
- Created the transitional care nurse navigator as the single touchpoint for all discharge-related activities, including supporting more care coordination across the entire continuum, as recommended by Fox Chase’s Patient Family Advisory Council
- Revised job descriptions, retrained existing staff, and hired and trained new staff
- Used a software solution to support new workflows and realize efficiencies
- Provided secure mobile messaging to improve communications
Results: Continued improvements in 30-day unplanned readmission rates as well as patient satisfaction scores related to discharge and care transitions.
Topics: Public Health, Quality Initiatives
Revision Date: 9/1/2019
Return to Previous Page