Nurse-Led Screening Tool Helps Connect Cancer Patients to Supportive Care Sooner
Key Takeaways:
- A nurse-led screening tool helped advanced cancer patients receive supportive care consultations earlier during hospital stays
- The pilot program identified high-risk patients using symptoms, readmissions and other advanced illness indicators
- Hospice referrals among hospitalized patients increased 264% after the nurse-driven referral process launched
“When my mom was a patient at Moffitt, supportive care medicine made all the difference for our family,” said Dana McClendon, a registered nurse care coordinator at Moffitt Cancer Center.
McClendon remembers how the supportive care team helped manage her mother’s symptoms, guided difficult conversations and ultimately made it possible for her to spend her final days at home on hospice.
“She passed peacefully, surrounded by family after a pizza party,” McClendon said. “Exactly the kind of ending we hoped for.”
That experience became the inspiration behind a nurse-driven project McClendon and colleague Tracey Mensing presented at the 2026 Oncology Nursing Society Annual Congress. Their work focuses on helping hospitalized patients with advanced cancer receive supportive care medicine consults earlier in their treatment journey.
Recognizing a Gap in Care
As nurse care coordinators working with value-based care patients, McClendon and Mensing noticed a troubling pattern. Many patients with metastatic solid tumors were repeatedly being readmitted to the hospital without ever receiving a supportive care medicine consult during earlier admissions.
“We kept asking ourselves, how are we missing these opportunities?” McClendon said.
At the time, supportive care referrals depended largely on provider discretion. Without a standardized process, some patients experiencing severe symptoms or declining health were not being identified early enough for additional support.
The nurses believed there had to be a more proactive and patient-centered approach.
Creating a Nurse-driven Trigger System
Using research and evidence-based models as a foundation, the team developed a simplified screening tool nurses could use to identify hospitalized patients who may benefit from supportive care medicine.
The trigger system assigned points based on factors associated with advanced illness and symptom burden, including:
- Metastatic solid tumors
- Uncontrolled symptoms such as pain, nausea, vomiting or shortness of breath
- Readmission within 30 days
- High distress scores
- Low albumin levels
- Recent thoracentesis or paracentesis procedures
Patients meeting the threshold score were referred for a supportive care medicine consult.
“A lot of times patients were going from very sick directly to hospice,” McClendon said. “Our goal was to start these conversations earlier.”
Supportive care medicine teams help patients manage symptoms, improve quality of life and discuss goals of care while patients continue cancer treatment.
“Patients may still be getting treatment, but now they also have a relationship with the supportive care team,” she said.
Earlier Support Led to More Hospice Referrals
The results of the pilot project were significant.
According to the presentation, inpatient supportive care medicine consultations increased following implementation of the nurse-driven referrals. Hospice referrals among inpatients also increased by 264%.
For McClendon, those numbers represent something more personal than metrics.
“That tells us we’re reaching patients earlier and helping them access the care and support they need at the end of life,” she said.
The project also highlights the important role nurses can play in improving care delivery by identifying gaps, advocating for patients and creating practical solutions.
Looking Toward the Future
The team hopes the screening process can eventually expand beyond value-based care patients and become more broadly integrated into inpatient and outpatient oncology care.
Future goals outlined in the presentation include collaborating with information technology teams to automate trigger-based notifications and extending the referral process into outpatient clinics.
McClendon believes the project’s simplicity is one of its strengths.
“We made it very basic and easy to follow,” she said. “If patients meet the criteria, they get the consult.”
For patients and families navigating advanced cancer, that earlier connection to supportive care may help improve comfort, communication and quality of life throughout treatment.
“Supportive care isn’t about giving up,” McClendon said. “It’s about helping patients feel better and making sure they have the support they need.”
