Follow-up calls after emergency department and in-patient encounters: Are we making a difference?

40 Background: The ASCO standard for tracking Emergency Department & In-patient (ED/IP) encounters was created to support process improvement, patient education, and timely follow-up after ED/IP encounters. Gaining access to ED/IP data from hospital systems to track and conduct follow-up calls is time consuming, operationally challenging, and expensive for practices engaged in advanced payment model programs. We reviewed data from our patient population to determine whether the Nurse Navigator ED/IP follow-up calls were helpful in the patient’s disease trajectory. Methods: A retrospective review was conducted from July to December 2024. Active patients, defined as having a cancer diagnosis and treatment within 90 days were uploaded into Virginia’s Care Coordination Health Information Exchange (HIE), which auto-generates reports for real-time ED/IP data. We reviewed all Nurse Navigator ED/IP follow-up calls. These calls were conducted within three business days of learning about the ED/IP discharge using a consistent script designed to address patients’ needs efficiently. Results: 1005 ED/IP encounters in July-Dec 2024. 53% Nurse Navigator connected with patient to conduct a follow-up call (n = 531): 22% (N = 116) of patient connections with a nurse navigator resulted in intervention, 21% Clinical intervention (n = 24), 31% Care coordination with surgery/other specialty intervention (n = 36), 48% Scheduling intervention (n = 56). Only 1% of patients that had a NN connection had an ED visit within one week. 24% Nurse Navigator left voicemail (n = 240). 23% No call: Patient died (n = 8); Office visit (n = 148); DC to hospice/SNF/Rehab (n = 10); Other (n = 68). Conclusions: In our patient population, 22% of patient connections with a nurse navigator resulted in intervention by the care team that supported positive patient outcomes. While not statistically significant due to low volumes, patients that had nurse navigator connections were ultimately less likely to have an ED/IP admission. We believe this evaluation showcases the real-world impact and importance of the ASCO standard for timely follow-up after hospitalizations and ED visits by nurse navigators.