Study: NCT02202096

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Medication reconciliation: Patient medication review
Description: The navigator will review the patient's medications with him/her prior to discharge.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Appointment before discharge: Additional measure to ensure awareness of next clinic visit
Description: Additional measures to ensure that patients are aware of the date, time, and place of their clinic visit(s) may include a phone calls or text messages to patients and their caregivers by the navigator, surgeon or clinic nurse.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Transition coach
Description: The navigator will assist with coordination of care and tracking follow-up appointments and tests.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Patient-centered discharge instructions: Enhanced
Description: Enhanced, language-specific, discharge instructions will be developed and provided to all patients verbally and in a written format designed for patients with limited literacy skills.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Provider continuity: Specific surgeons responsible for coordinating care with medical/radiation oncology
Description: Drs. Stefanos Millas (colorectal surgery) and Curtis Wray (surgical oncology) will be responsible for coordinating care with medical and radiation oncology as well as consulting when patients are readmitted to the hospital (if not admitted to the surgical service). Changes will be made to the clinic scheduling process for colorectal cancer surgery patients to minimize wait times, to allow them to be seen on a walk-in basis, and to prioritize visits for patients with urgent problems as identified by follow-up calls or inquiries to the Ask My Nurse hotline.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Timely follow-up: Barriers to clinic follow-up visits will be discussed
Description: Patients will be queried about financial barriers to clinic follow-up such as lack of money for parking and/or lack of transportation; parking vouchers and taxi/bus vouchers may be provided.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Timely PCP communication
Description: The operating surgeon will phone the PCP prior to and upon discharge to discuss concerns and follow-up care plans. Communication via the electronic medical record (EPIC) will also be sent. If the patient does not have a PCP, a referral will be made prior at the initial clinic visit and one provided.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Follow-up telephone call
Description: Patients will be contacted by phone by the navigator or surgeon on post-discharge day 1 to identify and address any concerns. If there are concerns, calls may be made on subsequent post-operative days.

Intervention type: OTHER
Group type: EXPERIMENTAL
Intervention: Patient hotline: 24 hour follow-up following call to Ask My Nurse number
Description: Follow-up will occur within 24 hours of calling the Ask My Nurse number. Patients with emergent problems will be seen immediately by the surgical oncology team if available or the on call surgery team. Patients with non-urgent matters will be called by a member of the surgical oncology team. Arrangements will be made to see the patient in clinic or the ER within the next 8-16 hours depending upon severity and time of day.