2025 CASE MANAGEMENT PRACTICE IMPROVEMENT (Honorable Mention)

PROJECT TITLE: Enhancing Navigation of Oncology Patients by Establishing an Inpatient Navigation Program

RECIPIENT: University of Texas MD Anderson Cancer Center

CATEGORY: Case Management Model

ABSTRACT: The University of Texas MD Anderson Cancer Center has developed an enhanced case management model to better meet the continuous and often complex needs of cancer patients across the continuum of care. Their model incorporates additional staffing, enhanced training, expanded care coordination activities, and technological support to improve the patients’ experience of care throughout their treatment journey. Comprehensive care planning anticipates post-discharge needs and facilitates access to essential community supports and resources. Discharge alerts were established to trigger staff outreach following the transition from inpatient care to outpatient treatment. The scope of the model is scalable. MD Anderson successfully implemented this navigation model across 21 units and trained 75 registered nurses. The new model reduces fragmented care and has significantly improved patient satisfaction. Additionally, patients are better prepared to manage their condition and navigate their treatment journey upon discharge.

RESULTS / OUTCOMES: The program has achieved significant improvements in patient satisfaction scores pertaining to care transitions. Patients also report a better understanding of their discharge information. A modest decrease in 7-day readmission rates was observed. A systematic implementation plan with monthly onboarding of units proved highly successful.