Innovative transitions of care nurse role to enhance same-day care coordination for cancer patients.

375 Background: At Stanford Health Care (SHC), the growing number and complexity of patients requiring same-day care coordination for urgent symptoms have strained outpatient capacity resources, leading to an increase in avoidable Emergency Department (ED) visits. In February 2024, SHC launched the Oncology Rapid Assessment Center (ORAC) to enhance care delivery by providing same-day urgent symptom management, expedited imaging, and infusion services in a specialized cancer care setting. An innovative Transitions of Care Registered Nurse Coordinator (TC-RNC) role was established to improve symptomatic triage support and streamline care coordination for same-day assessments across clinics, ORAC, and Infusion Treatment Areas (ITA). Before TC-RNC implementation, patients encountered challenges with phone-tree navigation and clinic response times, resulting in delays in triage and care for urgent symptoms. These delays contributed to excessive ED utilization by SHC-established cancer patients, accounting for 12.2% of all ED visits from July to December 2023. Methods: The TC-RNC team developed pathways for scheduling same-day appointments into ORAC, utilizing Schmitt-Thompson protocols and defined downgrade disposition workflows. This approach allowed TC-RNCs to consult directly with cancer-trained Advanced Practice Providers (APPs), reducing the need for ED diversions. A dedicated patient-facing triage line was established, providing specialized care advice and evaluations within 180 seconds from trained nurses, ensuring immediate access to clinical support. Results: From September 2024 to May 2025, the TC-RNC team triaged over 1,000 calls, successfully scheduling 63% of clinic and patient escalations directly into ORAC, referring 10% to ED, and 16% to clinic or ITA. Patient surveys conducted within ORAC indicated that, in the absence of TC-RNC and ORAC services, 63% of patients would have sought care in an ED. Implementation of this centralized triage model was associated with a 13.6% reduction in average weekly ED visits. Conclusions: The TC-RNC team exemplifies a patient-centered approach, effectively reducing ED visits, while enhancing same-day specialized cancer care coordination and continuity of care for patients. The success of this model highlights the need for ongoing evaluation and adaptation of care delivery systems to meet the evolving needs of cancer patients to enhance patient outcomes and satisfaction.