Skip to page content


Keeping Patients with Cancer at Home with 45% Fewer Admissions

TidalHealth Inc. proactively manages patients’ symptoms to keep them out of the hospital

For people going through chemotherapy, balancing treatments with tracking medications and symptoms at home can be overwhelming. One misstep, such as not drinking enough water or missing a temperature reading, can lead to an unexpected trip to the ED or a hospital admission. By proactively monitoring patients and reaching out to help them manage chemo-related symptoms, clinicians at TidalHealth Peninsula Regional have reduced unplanned ED visits and admissions for these patients by 45% in six months. 

Nurses in outpatient chemo areas review a score calculated with information from the Epic chart, such as a patient’s age, type of cancer, chemo regimen, and lab results, to see which patients are at risk for an ED visit or unplanned admission. For example, those taking multiple medications as part of chemotherapy are considered higher risk than those on a single medication. The nurses call high-risk patients before and after their chemotherapy treatments to discuss how they’re doing.

During these calls, nurses answer patients’ questions and make sure they feel comfortable with their treatment plan and home care regimen. For example, when patients start chemotherapy, they’re each given a care package including a thermometer, a water bottle to track how well they’re hydrating, and a symptom tracking sheet. They’re encouraged to record any symptoms, such as persistent nausea. When a nurse checks in, she and the patient can review the patient’s notes. 

“Managing a cancer diagnosis is challenging, and we never want patients to suffer from symptoms we can help prevent with a good home care regimen,” said Brandi Carr, director of operations for cancer services at TidalHealth’s Richard A. Henson Cancer Institute. “An encouraging phone call from a nurse can help address symptoms early and let patients know that we’re keeping an eye on how they’re doing day to day.”

Epic community members can learn more from TidalHealth’s presentation on the UserWeb.