(70) The Development of a Pediatric Hematology & Oncology Nursing Care Coordination Program: A Single Institution Experience

Session Abstract: Basis of Inquiry:

As outlined by multiple professional nursing organizations, the effective use of the nursing care coordinator (NCC) role optimizes patient outcomes and streamlines care transitions. However, the Association of Pediatric Hematology Oncology Nurses (APHON) does not provide a clear framework or recommendation for implementation of the NCC role in the pediatric hematology and oncology population. As a result, hospitals often struggle to effectively integrate care coordinators into the patient care team, leading to role ambiguity, workflow inefficiencies, and variations in care delivery.

Purpose/

Objective:

In 2023, St. Jude Children’s Research Hospital launched an initiative to establish a standardized NCC model for pediatric hematology and oncology patients. This initiative aimed to clearly delineate the NCC roles and responsibilities, standardize documentation workflows, improve transition management, ensure compliance with regulatory standards, and optimize resource allocation through data-driven decisions.

Methods:

Care Coordination standards provided by the American Academy of Ambulatory Care Nursing (AAACN) guided this initiative. Lean Six Sigma methodology provided a quality improvement framework. Care Coordination collaborated with multidisciplinary stakeholders to develop a RACI matrix, a tool that assigns levels of responsibility for tasks to each team member, ensuring clear communication and improved accountability. To enhance transition management and regulatory compliance, the team standardized documentation and utilized electronic health record (EHR) capabilities. Optimizations included a tailored discharge planning checklist and an integrated Patient Choice Form. Leveraging Epic reporting allowed analyzation of key metrics related to patient interactions, outreaches, caseload distribution, and care transitions. The NCC team then took a data-driven approach to make informed decisions about resource allocation to better support patient care.

Findings or Outcomes:

Implementation of a standardized NCC model improved role delineation, interdisciplinary collaboration and documentation workflows. The RACI matrix reduced role ambiguity, improved accountability, and eliminated redundancy while fostering interdisciplinary collaboration through a shared framework for task delegation. Revision of workflows and EHR enhancements significantly improved interdisciplinary discharge communication. The completion rate of discharge planning documentation increased from 33% to 90%, which not only ensured compliance with Det Norske Veritas (DNV) standards but also facilitated smoother transitions to post-acute care. The integration of the Patient Choice Form allowed care coordinators to pull the required Centers for Medicare and Medicaid Services (CMS) approved provider lists directly into the patient record and MyChart, thus improving family engagement in care autonomy. To support ongoing resource management, a new Epic dashboard enabled managers to monitor NCC activities including outreach efforts, clinic visits, inpatient admissions, monthly on campus patients, and overall case distribution. This real-time visibility allowed for proactive, data-informed decision making and better allocation of care coordination resources.

By implementing a standardized NCC model and integrating the care coordination role into the patient care team, St. Jude Children’s Research Hospital has achieved increased role

clarity, improved patient outcomes, and optimized resource utilization. These findings support the need for broader adoption of standardized NCC models across pediatric hematology and oncology settings to ensure consistency, efficiency, and high-quality care delivery.

Learner Engagement Strategies: Discussion, Question and Answer, Problem-Based Learning