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  1. Johnson, Shirley A. MS, MBA, RN
  2. Giesie, Pamela D. MSN, RN, CNOR
  3. Ireland, Anne M. MSN, RN, AOCN, CENP
  4. Rice, Robert David PhD, RN, NP
  5. Thomson, Brenda K. MSN, PHN, RN


We describe the development of an oncology solid tumor disease-focused care coordination model. Consistent with our strategic plan to provide patient- and family-centered care and to organize care around disease management teams, we developed the role of nurse care coordinator as an integral team member in our care delivery model. Managing a defined high-risk patient population across the care trajectory, these nurses provide stable points of contact and continuity for patients and families as they navigate the complex treatments and systems required to deliver cancer care. We describe role delineation and staffing models; role clarity between the role of the nurse care coordinator and the case manager; core curriculum development; the use of workflow management tools to support the touch points of the patient and members of the care team; and the incorporation of electronic medical records and data streams to inform the care delivery model. We identify measures that we will use to evaluate the success of our program.