| Sumario: | Significance & Background: Studies show that 41% of oncology patients are lost to follow-up after being dis-charged from the hospital. This statistic was reflected in the patient population at a Houston/Corpus Christi area oncology private practice. Losing patients to follow up after an admission leads to delays in patient care and poor patient outcomes. Purpose: A known concern within our practice was patients are being lost to follow-up due to unreported hospital events. This highlighted the need for a structured follow-up to establish a standard workflow to ensure continuity of care. Interventions: A Transitional Care Man-agement (TCM) workflow was developed using the criteria for TCM billing outlined by CMS. With this outline, we leveraged our Nurse Navigators (clinical staff) to ensure hospital follow up calls are made within 48 hours of discharge. During this interactive contact, the Nurse Navigator reviews intervention services, medications, concerns, and current health status with the patient. Using a stratification tool developed in collaboration with Nurse Practitioners, the provider is advised on the likely level of care needed during the follow-up visit. A hospital follow-up visit is requested within seven days for patients requiring high decision making and within 14 days for moderate decision making. Providers can adjust the patient's status per their clinical judgement if all other criteria are met. Results: During the first quarter (Quarter 4 2024) the program was active a total of 135 discharges were reviewed. That number consistently increased quarter over quarter (fig 1) with Q3 2025 showing a review of 597 discharged patients. This reflects a significant improvement in our tracking of hospitalized patients and subsequent discharges, thus leading to a higher rate of hospital follow-up visits. The addition of a post discharge call allowed Nurse Navigators to proactively discuss medication and intervention compliance and intervene when needed. In addition, other types of discharges were accurately tracked and reflected in the EMR. Discussion: Ensuring patients are not lost to follow-up prevents delays in treatment which leads to improved patient outcomes. Implementation of the TCM program has allowed for better tracking of not only patients discharged and at risk of being lost to follow-up, but also to knowing when our patients are transitioned to hospice care or died during an admission.
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