Bridging Gaps in Pain Management: A Qualitative Study of Nurse Navigator Roles.

Abstract Background The Edmonton Pancreaticobiliary Inflammation and Cancer (EPIC) Program is a nurse navigator (NN) led multidisciplinary coordination of care pathway aimed at improving care coordination, access to supportive services, and clinical outcomes for patients with pancreaticobiliary cancer. Aims Examine the perspective and experience of patients, their families, and healthcare providers (HCPs) in the EPIC program. Methods A mixed-methods design was used. Patient feedback was collected through a paper survey (N = 90), structured interview (N = 119), and NN notes documenting patient comments (N = 15). All patients and family members were eligible to participate. An online survey was distributed to a purposive sample of HCPs (N = 24) involved with the EPIC program. Quantitative survey data were analyzed descriptively, while qualitative data from interviews, nursing notes, and open-ended survey responses underwent thematic analysis. Results Patient feedback from surveys (n = 41, 46%), interviews (n = 63, 53%), and nursing notes (n = 15) generated nine themes. Overall, 85% of patients reported high satisfaction, citing emotionally supportive care, timely communication, effective coordination and navigation, improved access to investigations and symptom relief, and clear information provision. Among HCPs (n = 12, 50%), 83% felt the program met patient needs, 100% agreed multidisciplinary coordination improved, and 92% felt comfortable accessing the program. Positive program experiences included dedicated contact personnel, timely communication, and access to NN and dietitian. Patients valued emotional, medical, and resource-based support, while HCPs emphasized timely coordinated care, streamlined communication, and rapid access to referrals and investigations. Patient-suggested improvements included more written education materials, increased in-person contact, and extended program hours. HCPs recommended raising program awareness, simplifying referrals, funding to expand NN staffing, and broadening the scope to include additional hepatobiliary cancers. Conclusions The EPIC Program is highly valued by patients and HCPs. The findings strongly support continued investment in NNs, communication infrastructure, and program expansion to strengthen pancreaticobiliary cancer care. Funding Agencies None

Background and Purpose: Stroke causes approximately 165,000 deaths each year, making it the 5th leading cause of death contributing to an economic burden averaging $59,900 per patient annually. 80% of strokes are preventable through management of modifiable risk factors such as hypertension, diabetes, and smoking. Stroke Nurse Navigators (SNNs) were introduced in November 2020 as part of the hospital’s preparation for achieving Comprehensive Stroke Center designation. Since their implementation, the stroke program has grown from 299 stroke alerts annually to over 1,300. The SNN roles are to assist with stroke alerts, timely interventions, ensure inpatient stroke metrics are met using “Get With The Guidelines®” (GWTG), educating patients, families, and staff on modifiable risk factors and ensure secondary stroke prevention measures are addressed prior to discharge. Methods: All patients admitted with a diagnosis of ischemic stroke, hemorrhagic stroke, transient ischemic attack (TIA), or stroke rule-out are actively followed and audited by SNNs. Stroke order sets in both the Emergency Department and inpatient units include a consultation to the SNN, which automatically populates a patient list within the Electronic Medical Record (Epic). This ensures consistent tracking throughout the hospital stay. Regardless of final discharge coding, all patients are treated as potential stroke or TIA cases to ensure comprehensive evaluation, education, and adherence to stroke care protocols. Results: The national 30-day readmission rate for ischemic stroke in the U.S. is around 12-13%. For the time period of January 2025 - May 2025, our 30-day readmission rate is at 5.9%. In 2025, we achieved the GWTG Gold Plus with Target: Stroke Honor Roll Elite Plus with Advanced Therapy with Target: Type 2 Diabetes Honor Roll. This was our first time receiving the Advanced Therapy award since becoming a Comprehensive Stroke Center in June 2022. Conclusion: The addition of SNNs has significantly enhanced the quality of stroke care, even amid a substantial increase in stroke volume. By collaborating closely with staff and providers to emphasize the importance of GWTG and Quality Measures, SNNs ensure that patients receive timely interventions and appropriate secondary prevention strategies. Their involvement is instrumental in reducing stroke recurrence and improving long-term patient outcomes.

Background: Advancements in stroke care has enabled earlier hospital discharge. Both patients and caregivers express concerns about their ability to manage post-stroke care. There is limited evidence on supportive strategies, highlighting the need to improve care transitions. Purpose: This initiative aimed to reimagine the stroke care pathway by shifting from time-based interventions to a comprehensive episode-of-care model. Methods: Over a 48-month period, an interprofessional team collaborated to design, test, and implement an ideal patient experience across the stroke continuum. Components included redesign of educational materials, development of new workflows, strategic daily huddles, enhanced EMR tools, and integration of a Stroke Nurse Navigator. From August 2023 to June 2025, the project was rolled out in phases across 6 stroke centers and 5 rehabilitation facilities (figure 1). Reporting tracked specific metrics from initial stroke admission through community reintegration. Tactics included role restructuring,customized educational content, interviews with patients, caregivers, and staff. A flexible, multidisciplinary team was essential to ensure smooth transitions across care settings. Results: Figure 2 shows active patients. To date, 27 projects have been launched to enhance the patient/caregiver experience. Key outcomes include a 4% year-over-year increase in referrals to aligned inpatient rehab, home health, and outpatient therapy, reduction in 30-day hospital readmission rates, and increased neurology follow-up appointments at discharge. Lessons learned emphasize the value of listening to staff and patient feedback, maintaining momentum through daily staff check-ins, and adapting strategies to sustain improvements. Unexpected findings included early discharges from observation and emergency departments, missed referrals at discharge, provider engagement, and gaps in education and services contributing to unplanned emergency room visits. Conclusion: Stroke recovery is a complex journey that can overwhelm patients, caregivers, and healthcare providers. Integrated health systems have a unique opportunity to build infrastructure that supports recovery across all care settings. Sustained improvement requires continuous effort to address evolving needs and ensure seamless transitions. Stroke care pathways must evolve and use technology to meet the long-term needs of survivors. Early results suggest that episode-based care models can lead to improved outcomes.

HF is the most common reason for hospital admission and readmission of older adults and those readmitted within 30 days have a higher mortality rate at 6 months. The transition from hospital to community has been identified as a vulnerable time when patients must assume responsibility for their own care. No one strategy has been found to reduce 30-day readmissions or 6-month mortality rates. The Heart Failure Nurse Navigator (HFNN) is a home health registered nurse with specialized training in HF care. In this IRB-approved study, an HFNN visited intervention group participants once in the hospital, followed by weekly home visits for 1 month. Control group participants received usual care, with discharge teaching by nursing and follow-up with their provider. The qualitative research question was "What are the perceptions of older adults (≥65) with a diagnosis of HF who transition from hospital to home regarding care received from a Heart Failure Nurse Navigator?" Qualitative data were transcribed verbatim, then key thoughts and concepts were identified and organized into similar categories. Two main categories emerged: Personal Clarification of Patient Education, especially related to diet, exercise, and medications, and Feelings of Support, Reassurance, and Safety. Meeting the HFNN in the hospital was the beginning of the caring relationship that continued through the home visits. As the caring relationship developed, the HFNN, patient, and family determined together what mattered most during this crucial transition. Providing specialized HF instruction to home health nurses may give them a stronger base from which to offer comprehensive education, support, and reassurance to patients with HF.

Background: One of the leading causes of death in the United States is from a cerebrovascular accident, otherwise known as a stroke. Strokes are preventable by 80%; however, there is limited education and follow-up support. Patients are responsible for following up with their primary care provider after discharge. This poses challenges for the patient since they may not have family support. The role of a Stroke Nurse Navigator (SNN) is to provide education, address barriers, and provide support to the patient’s post-stroke recovery. Currently, SNN’s are not fully adopted as the standard of practice across all hospitals. Purpose: A SNN was introduced at a hospital in Northern California to explore the effectiveness in reducing 30-day readmission rates and 72-hour emergency room bounce backs, increasing follow-up adherence, and improvement of overall patient outcomes. Methods: Baseline data was collected from August 2024 through December 2024 (n=98) and again after implementation of a SNN (January 2025 through April 2025; n=87). Data included all patients admitted with either a cerebrovascular accident or transient ischemic attack. Data was collected based on 30-day readmission rates, 72-hour bounce-back rates, follow-up appointment adherence with their primary care physician, and patient satisfaction scores. Admission data, appointment attendance and survey scores were utilized to evaluate the effectiveness of the SNN. Results: When compared to pre-implementation numbers, the 30-day readmission rate was reduced by 49%. The 72-hour emergency room bounce back numbers decreased by 53%. Follow-up adherence increased by 56%. Patient experience surveys revealed that patients had a greater understanding of their diagnosis (previous average of 4.25 out of 5 to 4.61out of 5). Additionally, patients reported feeling more supported (previous average of 4.15 out of 5 to 4.83 out of 5). Conclusion: The introduction of an SNN reduced 30-day readmission rates and 72-hour bounce backs, increased follow-up adherence, and improved patient satisfaction scores. Findings from this study highlight the critical need of implementing SNNs across the nation.

HSD2 A Comprehensive Approach Including Mailed FITs and Nurse Navigation for Colorectal Cancer Screening

Sarcomas are rare cancers that pose complex treatment and psychosocial challenges, particularly in resource-constrained settings like the Philippines. Navigation plays a vital role in bridging gaps in care delivery. This article aims to define and describe the roles of a Sarcoma Nurse Navigator in a Philippine tertiary referral hospital and evaluate how these roles align with existing global literature. Using personal narrative and experience-based reflection, the authors identified seven core roles performed by the Sarcoma Nurse Navigator. The identified roles include: (1) Advocacy and Assessment, (2) Bridge to the Multidisciplinary Team (MDT), (3) Care Coordination, (4) Data Management, (5) Emotional Support, (6) Follow-up Care, and (7) Guidance for Resource Mobilization and Access Support. These roles reflect the different challenges cancer patients face in the Philippine setting and may serve as a template for other navigation programs in the country.

The Australian health care system continues to struggle to meet the needs of people experiencing multiple complex chronic conditions. Australians who report poorer health continue to report poorer access to health care. Inequities in access are attributed to a "mistmatch" between the health care system and individuals' clinical and social needs. To address this misalignment at the interface of access, innovative approaches that consider both individual and system-level barriers to care need to be examined. Nurse navigation models designed to support people negotiating complex care and bridge systems and service gaps have been touted as a method to enhance access, but how nurse navigators work at the interface of access in practice is unclear. This qualitative study examined the mechanisms by which nurse navigators facilitate access to care for people experiencing complex care needs through an exploration of key stakeholder perspectives: nurse navigators, nurse navigator patients, and care professionals. Data collection involved in-depth semi-structured interviews, and analysis included reflexive thematic analysis and data triangulation processes. A conceptual framework of access to health care was used to explore nurse navigators' roles at both system and patient levels. Nurse navigators supported both patients and care professionals by building relationships across the interface of access, challenging norms of care, and facilitating empowerment. Nurse navigators acted as intermediaries to negotiate access, work made possible through their knowledge of systems and capacity to identify and respond to multidimensional care needs and systems challenges. This research highlights the importance of holistic and relational approaches to overcome issues of access for all involved.

Background: Breast cancer is the most common malignancy among women in Pakistan, with one of the highest mortality-to-incidence ratios in Asia, largely due to delayed diagnosis and treatment initiation. Sociocultural barriers, healthcare system inefficiencies, and patient-level factors exacerbate these delays, resulting in advanced-stage presentations and poor outcomes. Nurse navigation, an evidence-based strategy for coordinated oncology care, has shown promise in addressing such barriers but remains underutilized in low-resource settings. Objective: This study aimed to evaluate delays across the breast cancer care continuum and assess the effectiveness of nurse navigation in reducing diagnostic and treatment delays and improving psychosocial readiness among patients. Methods: A cross-sectional observational study was conducted among 81 breast cancer patients at a tertiary care hospital in Lahore. Participants were assigned to either a nurse navigation group receiving structured coordination and counseling services or a usual care group. Delay intervals, distress, and readiness scores were measured and analyzed using descriptive and inferential statistics. Results: Nurse navigation significantly reduced clinic-to-treatment delays (46.0 ± 32.1 vs. 78.3 ± 41.2 days, p < 0.001) and improved readiness to cope (4.45 ± 1.22 vs. 3.62 ± 1.58, p = 0.009). Delays increased with disease stage, while readiness declined, highlighting the dual logistical and psychosocial impact of navigation. Conclusion: Structured nurse navigation effectively shortens treatment delays and enhances patient preparedness, offering a scalable, patient-centered solution to improve oncology care in resource-limited healthcare systems.

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.

185 Background: Patient navigation has been found to improve patients’ clinical outcomes. The service-line nurse navigators (NNs) at our fourteen-hospital network serve patients with newly diagnosed malignancy and have two main objectives: facilitating the timely initiation of treatments and improving patient experience. The evaluation was a critical component of our program charter and included the number of patients contacted by the NNs, the time to treatment initiation among these patients, and the number of referrals to support services by the NNs. The implementation and sustainability of each evaluation strategy are discussed. Methods: We integrated the evaluation metrics into the patient tracker spreadsheet maintained by the NNs. Because the largest subset of patients served through the program were diagnosed with stage IV non-small cell lung cancer, the quality improvement specialist conducted a chart abstraction of this group to assess the duration from diagnosis to treatment initiation. This duration was compared to a historical sample obtained from the tumor registry data. Results: During the first nine months, the navigators served 147 patients. The mean age was 69 years. Eighty-two percent identified themselves as Caucasian, 8 percent as African American, and 4 percent as Asian. Fifty percent identified themselves as male, 48 percent as female, and 2 percent as other or undisclosed. There was no transgender patient. Fifty-five percent had Medicare or Medicare Advantage, 27 percent had commercial insurance, and 10 percent had Medicaid. The largest number of referrals, 51 percent, came from inpatient clinicians. Eighty-three percent of patients established outpatient oncology care within our hospital network. Care barriers included lack of transportation and comorbidities requiring complex care coordination. The tracker did not capture all referrals to psychosocial support; only 15 referrals were noted. Nine patients with stage IV non-small cell lung cancer were diagnosed at our medical center and established care at a local community hospital. The average length between the diagnosis and treatment initiation was 42.9 days (n = 9, SD = 22.4), compared to an average of 51.1 days (n = 34, SD = 44.3) among the historical cohort of tumor registry patients with the same disease and cancer stage who also out-migrated from our medical center. Conclusions: The program evaluation highlighted the opportunity to increase referrals from outpatient providers. We observed a trend toward a shorter duration between diagnosis and treatment among our patients compared to the historical comparison group, indicating the program’s potential effect in preventing significant treatment delays. Lessons learned included focusing on improving navigator onboarding related to data capture. Finally, we plan to utilize the reporting function in our electronic health records to minimize manual data tracking and monitor outcome measures.

The Race to the Bottom: A High-Volume Hospital Experience With Comprehensive Care for Joint Replacement.

584 Background: Caring for cancer patients requires Multidisciplinary Tumor Boards (MTB). With the COVID pandemic, the structure of MTB had adapted from an in-person to a virtual format, posing challenges with collaboration and participation. The purpose of this study is to examine perceptions of virtual Thoracic MTB to its participants, and how this might impact the MTB utility and recommendations. Methods: Survey data was collected from 75 participants of Thoracic MTB between August and October 2022. A Likert scale was utilized to capture participant perception of Thoracic MTB, what areas of Thoracic MTB need improvement, and how likely participants would follow recommendations suggested at Thoracic MTB. Participants could also add comments at the end of the survey to discuss their thoughts on tumor board and the changes made during the pandemic. Descriptive statistics and regression analysis were utilized to analyze the results. Results: Table 1 depicts a few of the participant characteristics. On average, participants “to a great extent” felt that Thoracic MTB improved care and outcomes for their patients and increased knowledge about treatment paradigms. Participants to a “minimal or slight extent” felt judged presenting patients or asking questions. Most felt that “organization”, “pre-meeting communication”, and “lack of follow-up” were some of the challenging aspects of Thoracic MTB. Conclusions: The survey data indicated an overall positive response to the hybrid format of Thoracic MTB during the pandemic. Many felt that the virtual format allowed for satellite centers within the healthcare system to consistently participate in Thoracic MTB and gain assistance in treating complex patients. 60% of participants noted that the virtual aspect of Thoracic MTB improved their experience. However, there was concern that collegiality was less apparent as Thoracic MTB used a virtual formal; a few noted feeling intimidated when speaking online. Our institution chose to move to a hybrid format with in-person and virtual attendance in May 2023. More research is needed to determine success factors in experience, value, and impact for other tumor boards that have a virtual option. Participant characteristics. Medical Oncology Radiation Oncology Surgical Oncology Pulmonary Medicine Pathology Radiology Nurse Navigator Other n 18 12 3 17 4 4 6 11 Most common range of time spent with organization 0-5 years 6-10 years 11-25 years 11-25 years 11-25 years 11-25 years 11-25 years 6-10 years Most common range of distance from MTB site <5 miles 10-20 miles <5 miles <5 miles <5 miles <5 miles <5 miles 5-10 miles n = sample size.

276 Background: During and after the COVID-19 pandemic, a significant decrease in cancer screening was observed. Cancer screening and prevention are critical initiatives to address community needs and are required by the American College of Surgeons’ Commission on Cancer (COC) Standards. The cancer center leadership of our academic medical center launched an education and screening initiative to reduce disparities in prevention and early detection. Methods: A multidisciplinary team evaluated cancer screening rates across 11 system-affiliated primary care practices. The data was stratified by race, language, and zip code. Clinics with low screening rates, diverse populations, and high volumes were prioritized. Over the five years of the initiative, multiple cycles of Plan-Do-Study-Act were implemented to continuously improve the program. Patient outreach included portal messages, multilingual texts, and educational materials across the healthcare network. Results: The program spanned two medical centers and five community clinics over the four years. Between 2021 and 2025, the initiative engaged over 350 patients through community events, with 75% requesting follow-up screening information. Nurse navigators supported patients seeking screening procedures. One patient re-established primacy care and screening at a community center after being lost to follow-up due to losing commercial insurance. Conclusions: Since the launch of this initiative in 2021, cancer screening efforts for breast, cervical, and colorectal cancers have shown meaningful progress, particularly among Latinx and limited English proficiency populations. The program now includes on-site activities at two hospitals, with plans to expand to four additional sites by 2026. We continue to enhance patient education and community-based support to advance equity in cancer prevention and reduce barriers to care across underserved populations. Year / Screening Focus Plan / Do 2021 Colon Separate provider and patient education webinars; Provider event focused on Cancer Genetics and patient event on nutrition with cooking demonstration. 2022 Lung Use of Health Equity Dashboard to guide efforts; Development of patient education video of screening test to dispel myths. 2023 Cervical Addition of walk-in clinic for screening at community site. 2024 Colon Addition of Spanish in-person education event and navigator follow-up for screening appointments. 2025 Cervical Focused outreach to LGBTQ+ pts with gender affirming screening options.

473 Background: Retrospective chart review identified variation in initiation of neoadjuvant chemotherapy in our breast cancer population, leading to reduced patient and provider satisfaction and increased patient anxiety. We aim to decrease the percentage of eligible triple-negative or Her2+ breast cancer patients with ≥14-day delay from the initial medical oncology consult to start neoadjuvant chemotherapy by 50% by June 2024. Methods: Through participation in the ASCO Quality Training Program, our multidisciplinary team identified key barriers to timely care, specifically around the lack of pre-consultation preparation. Six months of retrospective analysis, cause and effect mapping, and Pareto chart indicated two primary causes for the delay: port placement/imaging delays with outside entities and lack of coordination between RN and MD to prepare anticipated needs. To address this, our breast cancer physician committee developed a neoadjuvant pathway aligned with National Comprehensive Cancer Network (NCCN) guidelines. Utilizing Plan-Do-Study-Act (PDSA) framework, the Oncology Nurse Navigator (ONN) screens patients for eligibility ensuring prompt identification. ONN educates patients on their tumor characteristics, pathology, and neoadjuvant treatment rationale. An order set was initiated, including echo, chemotherapy education visit, labs, and port placement scheduled to occur following initial medical oncology consultation. Results: Retrospective data (n=28) showed a mean of 16.4 days with 40% of this population starting chemotherapy > 14 days from consult. Initiation of the PDSA cycle with ONN pathway and order sets reduced the mean start to 11.5 days (n=15), reduced the upper control limit (UCL) from 45.4 to 23.9 days, with a 50% reduction in patients starting chemotherapy >14 days from consult. Conclusions: Developing disease-specific clinical pathways, and engaging ONN to identify patients for pathway eligibility, utilizing order sets, and educating patients about upcoming visits and anticipation for neoadjuvant chemotherapy resulted in a significant reduction in time to initiate neoadjuvant therapy for our cohort of breast cancer patients.

152 Background: We present a two-year update on the Cancer Diagnostic (CDx) clinic, which evolved from a pilot feasibility project into a sustainable, system-level intervention at the University of Pennsylvania Health System (UPHS). Designed to expedite the diagnostic workup for patients with suspected cancer, streamline testing, and ensure timely transition to subspecialty oncology care, we aimed to improve patient experience and cancer-related outcomes. Integrated into existing clinician panels, the clinic is staffed by medical oncologists, fellows, NP, oncology nurse navigator, RN, and LCSW. Through a phased referral rollout and iterative process improvements, the clinic expanded access, increased referrals, and maintained efficient time intervals from initial visit to diagnosis and treatment. Methods: The QI initiative began as a phased pilot in March 2022 and, following early improvements in system throughput, was formalized as a permanent UPHS program. This report presents data from March 2023 to March 2025. Referrals, both external and internal, were introduced over seven Plan-Do-Study-Act cycles, including 4 EDs, 24 Hospital Medicine teams across four sites, a PM&R team, and UPHS PCPs plus 27 county PCP networks. Epic referrals were submitted via an “Oncology Nurse Navigator Services” order, later transitioned to a dedicated “Consult to Cancer Diagnostic Clinic” order. Outcomes included referral volume, new patient visits (NPVs), time from referral to NPV, time from NPV to tissue-confirmed diagnosis and first cancer-directed treatment, Vizient length of stay (LOS), cancer type, and UPHS retention. Statistical process control charts tracked trends. Results: During the study period, 834 referrals resulted in 241 patients seen in clinic, averaging 9 NPVs/month. Median time from referral to NPV, diagnosis, and treatment was 6, 8, and 31 days, respectively—improved from baseline intervals of 7, 21, and 42 days. Vizient LOS declined from 8 to 4 days, and the observed-to-expected ratio improved from 1.27 to 0.78. New cancer was diagnosed in 63.1% (n = 152), most commonly GI (36.8%, n = 56), thoracic (22.4%, n = 34), and hematologic (19.1%, n = 29) malignancies. Two patients enrolled on a therapeutic clinical trial, and 97.7% remained in UPHS for ongoing care. Conclusions: By leveraging a multidisciplinary team, the CDx clinic streamlines referrals and improves timely access while reducing time to diagnosis and initiation of cancer-directed therapy. The clinic continues to expand and refine referral pathways—redirecting diagnostic efforts to coordinated, oncologist-led outpatient evaluation, reducing unnecessary admissions, and shortening LOS. This adaptable, team-based model offers a scalable framework for institutions seeking to reprioritize resources and improve cancer care coordination, diagnostic efficiency, and outcomes across a multifaceted care continuum.

423 Background: The Enhancing Oncology Model (EOM) is a voluntary payment and care delivery model of the Centers for Medicare & Medicaid Services. Participants are required to report disability status for each beneficiary starting Performance Period 3 (PP3). Willamette Valley Cancer Institute and Research Center’s (WVCI) baseline data showed that no EOM beneficiaries had electronic health record (EHR) documentation of disability status prior to PP3. The aim of this project was to improve collection and documentation of disability status, consistent with EOM requirements. Methods: We undertook the ASCO Quality Training program (QTP) in July 2024. The core team assembled an interprofessional workgroup comprising Quality Management, a physician champion, nursing, patient access team, support services, and medical assistants to understand performance variation. We followed the ASCO QTP process to collect baseline and diagnostic data, create process mapping and cause/effect diagramming, and develop an action plan. We completed two full PDSA cycles (Table). Organizational restructuring occurred during this period, resulting in new assignments for collecting and documenting disability status, with the ultimate goal of transitioning responsibility to the care team. Disability status documentation improved to 82%. Results: See table. Conclusions: Collecting and documenting disability status in the EHR is critical for meeting the needs of EOM beneficiaries to provide equitable, high-quality care. WVCI has developed a sustainable process for the initial collection and annual update of disability status. Next steps include optimizing disability documentation through additional tools such as EHR alerts. Furthermore, we are collaborating with other practices and disability workgroups to advance our work. Date PDSA Cycle PDSA Description Results 6/14/2024-9/13/2024 1 Pre-Implementation Phase:Developed disability collection education, intake form, scripting, and EHR template/documentation tipsheet Developed plan and workflow with staff and leadership Nurse Navigator team piloted new process 27.5% (97/352) 9/16/2024-10/14/2024 2A Collected Nurse Navigator team feedback on process, resulting in transitioning disability status collection to lay patient navigators, which resulted in a temporary decrease in documentation 3.6% (13/352) 10/14/2024-11/8/2024 2B Lay patient navigator team collected disability status Disability status transitioned to the care team after administrative reorganization 43.4% (153/352) 12/31/2024 Post-Project Results 82% (342/413)

Improving the Quality of Whole-Person Healthcare Delivery Critical Components of a Sickle Cell Disease Nurse Navigator Role.

Background:Women Veterans are the fastest-growing population in the Veterans Health Administration (VHA), but little is known about how to identify and address their social needs. This program evaluation examined the implementation of a social screening and referral initiative, Assessing Circumstances and Offering Resources for Needs (ACORN), using nurse navigators in a VHA women’s health clinic.Objectives:(1) Describe the implementation process and outcome measures, (2) assess the prevalence of women Veterans’ social needs, (3) characterize nurse navigators’ perceptions of ACORN, and (4) document implementation challenges and adaptations.Research Design:Program evaluation with qualitative and quantitative data collected between March 2023 and November 2024. Descriptive statistics were used to summarize sociodemographic characteristics and social needs of Veterans screened.Subjects:Veterans receiving continuity care at a women’s health clinic in a midwestern VHA hospital.Results:Nurse navigators completed ACORN screens with 291 Veterans, with 67% screening positive. The most frequently reported needs were social isolation/loneliness (49%), utilities (17%), transportation (14%), and digital needs (13%). Nurse navigators and the nurse site champion reported that ACORN enhanced their understanding of patients’ social needs and their ability to address these needs. They also reported seamless integration of ACORN into existing workflows.Conclusions:Findings show early insights into women Veterans’ unique social needs. An innovative nurse navigator approach to social screening in a VHA women’s health clinic was feasible, had high likelihood of sustainment, and improved nurses’ ability to care for their patients. This indicates strong potential for expanding nurse navigator roles both within and outside VHA.