Case Study: Fox Chase Cancer Center 2019 HAP Achievement Award

Awarded for: Optimizing Care Transitions: Reimagining Case Management
Optimal Operations
Small Organizations

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.

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Topics: Public Health, Quality Initiatives

Revision Date: 9/1/2019

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