Transitional care management for cancer patients: Extending general models of population health management to an oncology specific population.

282 Background: Providing Transitional Care Management (TCM) during the initial 30-day post-discharge period, has proven effective for reducing readmissions among chronically ill and geriatric populations. Care managers proactively contact patients, elicit patients’ challenges and then coordinate interventions. We aimed to extend the Transitional Care Management model to an Oncology specific population. Methods: We conducted a 4-month pilot study of Transitional Care Management among patients discharged from a large, dedicated cancer center between August – December 2024. Patients included in the pilot had received care for one of four conditions-Sarcoma, Lymphoma/Myeloma, Endometrial Cancer or Pancreatic Cancer. During the study period, patients targeted for Transitional Care Management received recurring telephonic outreach from trained Nurse Transitional Care Managers (TCMs) to screen for symptom exacerbation, pain control, medication reconciliation or other unmet needs. Service delivery followed standard workflows, and all nurses followed standard issue escalation pathways based on the clinical guidance of physicians with expertise in their assigned disease site. At the conclusion of the initial pilot period, we evaluated the impact of Transitional Care Management on 30-day readmission rates. Results: During the pilot study period, 972 patients were eligible for the TCM program, 715 (73.6%) were assigned a TCM, 423 (59.1%) were assessed at least once and 274 (38.3%) had a TCM intervene to provide medical guidance, address resource needs or provide other support. The readmission rate for all eligible patients was 23.5%. The readmission rate for patients assessed by a TCM was 18.5%. Comparing observed and expected outcomes across groups we calculated a statistically significant chi-square value of 9.53 (p < 0.01) and an unadjusted odds ratio of 1.62 (p < 0.001). This indicates that patients assessed by a TCM were less likely to readmit than those who were eligible for the program but did not engage. Conclusions: Patients assessed by a TCM had a lower readmission rate than eligible unmanaged patients. One limitation of our analysis is that it does not control for inherent differences that may exist in the managed and non-managed populations. Future work should focus on ensuring all patients in the program receive frequent outreach. Future analysis should focus on understanding whether group differences in outcomes are due to the care provided by TCMs or based on inherent differences between those patients who engage and those who do not.