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Evidence-Based Oncology October 2016
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A Holistic Approach to Cancer Care: Focus on Collaboration

Surabhi Dangi-Garimella, PhD
Healthcare providers and health plans are evaluating different care models in the clinic to understand what works best with ensuring continuity of care and improving outcomes.
Collaboration is key to the success of any business venture, and healthcare should be no exception. Yet time and again, we encounter gaps in patient care that stem from mis­communication or lack of communication among those involved in patient care, and this could result in decisions that lead to adverse outcomes.
The lack of cohesion highlights several aspects of the care delivery system:
  • Fragmented care delivery
  • Lack of interoperability between data systems used by health­care clinics and academic centers
  • Failure of communication among the following:
    • healthcare providers who participate in patient care
    • patient and provider
    • provider and family caregivers
  • Gaps in care transitions, especially with survivor care (Figure)
Such disjointed care can yield questions that are left open for interpretation by physicians, radiologists, or nurse practitioners who may not be communicating with oncologists. The end result could vary from inappropriate treatment to a lack of adequate treatment—an unnecessary burden on healthcare costs. To ad­dress this, several different models have been developed for more seamless patient care.


Role of Health Navigators

Support received from a nurse navigator can significantly improve the patient experience and reduce problems in care, according to a study published in the Journal of Clinical Oncology.1 The trial enrolled newly diagnosed cancer patients and divided them into a control group that received usual care and an intervention group that received support from a nurse navigator for 4 months. Patients were assessed using several patient-reported outcomes measures at baseline, at 4 months, and at 12 months. Although there was no difference in the quality-of-life between the 2 groups, patients with lung cancer who received guidance from a nurse navigator had lower healthcare costs (average $6852).
Another study used nurse navigators at imaging centers to identify women at greater risk of hereditary breast and ovarian cancer (HBOC) syndrome as a preliminary screening method. The study enrolled 1420 women (seeking imaging/screening or breast biopsy results) at 3 mammography and imaging centers to use the HBOC risk assessment tool coupled with a nurse navigator to identify who may be at risk for HBOC. As a result of the program, fewer women required HBOC education and evaluation and a greater number of women with positive biopsy results were found to be at risk for HBOC compared with similar studies. Knowing patients’ risk of HBOC during biopsy helped direct clinical decisions on the kind of surgery that would be needed.2
Spectrum Health, a health system in Grand Rapids, Michigan, provides its patients access to an oncology nurse navigator, from prediagnosis through survivorship and end-of-life care. The nav­igator serves as the pillar of support for patients and their family members by offering the following3
  • Help navigating complex treatment by serving at the point of contact
  • Education about disease process and treatment
  • Psychosocial support
  • Liaison between specialists and family physician
  • Seamless care transitions by removing barriers to care
  • Connections with services, including social work, nutrition counseling, genetics, research, pastoral care, physical and occupational therapy, and financial counseling
Patient and Caregiver Engagement: Self-Management and Patient-Reported Outcomes
Engaging patients in their own care is extremely important, as pa­tients can be their own best advocates. Being aware of their condi­tion and cognizant of the effects of various treatments, patients can be the focal point of contact for the providers integral to their care and can also provide input in terms of patient-reported outcomes.
Symptom management is the primary goal of patient engagement and the foundation of patient-centered care that can improve both outcomes and quality of life. Although information is crucial for patients to feel they are in control, with minimal interruptions of their daily activities, each person’s inherent ability to manage these symptoms will vary within a population. To overcome this discrepancy, researchers have developed the Theory of Symptom Self-Management so clinical outcomes can be maximized via patient-friendly tools that allow the patient and the physician to collaborate on tailored, achievable, goal-oriented plans for symp­tom management.4
Family caregivers should be actively engaged in care manage­ment, and physicians must ensure communication with the patients’ family members on all aspects of care—from diagnosis and treatment options through survivorship and end-of-life issues. The National Cancer Institute has developed a compre­hensive guide that provides step-by step instructions for both physicians and patients on the role of a family caregiver in caring for cancer patients.5
Along the lines of patient involvement in their own care, a study conducted in the Urology Department at the University of North Carolina at Chapel Hill included patient values and preferences when developing treatment plans for patients with prostate can­cer. Using a Web-based application equipped to provide educa­tion, preference measurement, and personalized decision analysis for newly diagnosed patients with prostate cancer, the research­ers enrolled 109 men to complete the application prior to their consultation. The result was a significant reduction in decisional conflict (37%; P <.0001); further patient satisfaction with the pro­cess was high, as they felt more involved with, and responsible for, treatment decisions.6
The Medical Home Model
The medical home model—be it the patient-centered medical home (PCMH) or the oncology medical home (OMH)—is a pro­ponent of team-based care. The OMH model has evolved from the PCMH, which promotes a physician-directed network of care that may be provided by other physicians, nonphysician providers, or allied ancillary health services. The first such model was commis­sioned by John Sprandio, MD, in 2010, when the National Com­mittee for Quality Assurance recognized his 9-physician oncology practice as a PCMH.7 The practice boasted a reduction in unnec­essary resource use, including:
  • 68% reduction in emergency department (ED) visits
  • 51% reduction in hospital admissions for patients on chemo­therapy
  • 21% reduction in hospital length of stay
The clinic estimated that it saved insurance plans an average $1 mil­lion per physician per year when the paper was published in 2012.
Along the lines of the OMH is the Community Oncology Medical Home, the COME Home program, developed by Innovative Oncol­ogy Business Solutions, which was implemented in 7 oncology practices across the country using a grant sponsored by the Center for Medicare & Medicaid Innovation. The program uses triage nurses up front to direct patients when they call the clinic; this service is available 24/7. Additionally, the clinics have extended office hours through the week and they implement clinical pathways to ensure standardized treatment. COME Home practice sites have seen between a 23% and 28% reduction in ED visits.8
The PCMH seems an ideal model, but with pro­vider shortages, especially oncology care providers, physician assistants (PAs) and nurse practitioners (NPs) could play an important role in team-based care to improve productivity. There are, however, several considerations to this role-sharing by nonphysician staff, and clinics would need to con­template the following:9
  • A clear delineation of provider roles to maximize efficacy
  • A well-defined communication plan among team members
  • A feedback loop to measure quality of care and cost-efficiency of the process
  • Institutional credentialing and licensing may be different for PAs and NPs
  • From the reimbursement point of view, productivity tracking should be accurate for billing purposes.
Building a transactive memory within, and between, teams of care providers, who might be a part of a single healthcare system or collaborating across healthcare systems, can significantly impact patient care and outcomes. The process requires 2 or more team representatives to develop a shared system for encoding, storing, and retrieving information, wherein each professional is respon­sible for retaining only part of the total information. The patient, meanwhile, functions as the unifying member of the teams and is central to successful care delivery.10

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