Improving post-discharge appointment coordination for hospitalized cancer patients utilizing inpatient patient service coordinators.

Abstract

e13561 Background: Hospitalized cancer patients often require complex post-discharge care, including oncology follow-up, imaging, and laboratory testing. Failure to schedule these appointments prior to discharge may delay care, increase patient and caregiver burden, and contribute to fragmented care transitions that may increase readmission risk. As part of a broader hospital throughput initiative, we implemented a multidisciplinary quality improvement project to improve post-discharge appointment coordination on an inpatient oncology unit caring for melanoma, sarcoma and gastrointestinal medical oncology patients. Methods: The project occurred between March 1-31, 2025. The intervention included electronic health record (EHR) modifications to identify post-discharge orders, training inpatient patient service coordinators (PSCs) to directly schedule or transfer discharge-related orders through a dedicated work queue, and provider education to promote timely order entry using the discharge navigator. An EHR-embedded dashboard was developed to enable real-time monitoring of scheduling performance by unit, service, and provider. The primary outcome measure was the proportion of post-discharge orders scheduled prior to discharge. Results: During the study period, 44 patients were discharged and the median length of stay on the pilot unit was 7 days. Among 99 post-discharge orders placed in the scheduling work queue, 80.8% (n = 80) were scheduled prior to discharge, representing an improvement from a baseline average of 57%.The majority of orders were laboratory testing (n =52, 52.5 %), clinic follow-up (n =38, 38.4%), imaging (n =3, 3%), and other (n =6, 6.1%). Among scheduled orders, 40.4% (n =41) were scheduled directly by inpatient PSCs, with the remainder transferred to outpatient scheduling teams. Real-time dashboard access supported sustained performance through targeted feedback. Conclusions: A scheduling model incorporating inpatient PSCs supported by EHR optimization and real-time performance monitoring substantially improved post-discharge appointment coordination for hospitalized cancer patients. Based on early success, this model is now being expanded across the institution. The ongoing effort aims to improve the reliability of care transitions, with the potential to decrease delays in oncology follow-up and help reduce avoidable hospital readmissions.