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seamless transfer of new patients from inpatient to outpatient

  • 1.  seamless transfer of new patients from inpatient to outpatient

    Posted 05-23-2019 13:31
    We are grappling with an issue that I hope someone has some insight with.  When a new to the oncology/heme service patient is discharged and needs immediate outpatient care, what is the process to provide that and who does until the newly assigned attending hasn't seen the patient yet?
    That is, who follows lab results and orders any needed treatment?  Also, when and how is the outpatient provider assignment made?  Does case management assist?  New patient coordinators?  Do these new patients get seen by the outpatient provider or RN while they are still inpatient?

    Joy Lombardi, BSN, RN, OCN
    Nursing Director
    Huntsman Cancer Institute
    Salt Lake City, UT

  • 2.  RE: seamless transfer of new patients from inpatient to outpatient

    Posted 05-24-2019 08:43

    ​I've worked in several different pediatric hem/onc/HSCT institutions. Everywhere I've worked, when a patient is diagnosed inpatient they have some sort of connection with the clinic prior to being discharged as part of their discharge criteria. Most institutions I've worked for, the patient and family will get a tour of the clinic prior to discharge. Otherwise the clinic nurse who will be the primary for the patient has come inpatient to do some teaching and explain the clinic process.

    The rest of your questions sound like it might be a difference between the pediatric and adult world. Everywhere I have worked the attendings work both inpatient and outpatient. There is a lot of fluidity, good communication, and usually we don't have issues. Patients who are newly diagosed usually have a clinic appointment the day following discharge or just a few days later. If they would need urgent help before their first scheduled clinic appointment it would be handled like an established patient.

    As for how the primary attending gets assigned I've seen a lot of variation. Sometimes it's the attending who diagnosed the patient. Sometimes it's whoever has the fewest patients on their current panel. Sometimes it's family request. Sometimes it's attending request. Sometimes it's based on when their inpatient treatment was given, when it's due next, and whose clinic day that is.

    Amanda Lulloff PhD RN PCNS CPHON
    Clinical Nurse Specialist
    Blank Children's Hospital

  • 3.  RE: seamless transfer of new patients from inpatient to outpatient

    Posted 05-24-2019 09:02
    Hi Joy!
    We have inpatient nurse navigators who help facilitate discharge planning and provide the patients as well as our outpatient disease specific nurse navigators their contact information to follow-up and help with the transition from IP to OP care.

    In our community cancer center, physicians or APRN's who are affiliated with the oncology practice will see them inpatient, they may not see them as an outpatient but someone from their practice will. Effective communication and discharge planning between the inpatient & outpatient NN team really helps with this process.

    Please feel free to reach out if you need more information.


    Darcy Burbage RN MSN CBCN
    Supportive and Palliative Care Nurse Navigator
    Newark DE

  • 4.  RE: seamless transfer of new patients from inpatient to outpatient

    Posted 05-24-2019 09:48
    ​Good morning Joy,
     I actually operate in that space as a newly created transition care manager role. I meet with the pts and  coordinate their appts and we also have NP led Transition care clinics (TCC) that I get the pt into if they can not be seen by the primary physician in a timely manner. They are set up for blood work and possible transfusions as well all prior to discharge.

    Dianne Hyman MSN RN
    Transition Care Manager
    MD Anderson Cancer Center At Cooper
    Mount Laurel NJ