A Holistic Approach to Cancer Care: Focus on Collaboration

Evidence-Based Oncology, October 2016, Volume 22, Issue SP14

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 can&shy;cer. Using a Web-based application equipped to provide educa&shy;tion, preference measurement, and personalized decision analysis for newly diagnosed patients with prostate cancer, the research&shy;ers 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 pro&shy;cess 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 pro&shy;ponent 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 commis&shy;sioned by John Sprandio, MD, in 2010, when the National Com&shy;mittee for Quality Assurance recognized his 9-physician oncology practice as a PCMH.7 The practice boasted a reduction in unnec&shy;essary resource use, including:

  • 68% reduction in emergency department (ED) visits
  • 51% reduction in hospital admissions for patients on chemo&shy;therapy
  • 21% reduction in hospital length of stay

The clinic estimated that it saved insurance plans an average $1 mil&shy;lion 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 Oncol&shy;ogy 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 pro&shy;vider 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 con&shy;template 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 respon&shy;sible 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

A ROLE FOR INSURERS

Cigna, a health insurance service company, has developed its own Cigna Collaborative Care program modeled on the account&shy;able care organization principle: it depends on a network of large and small health practices and hospitals, and needs a primary care component for the physicians to be responsible for the health of their patient population.11 The fulcrum of this col&shy;laborative structure is a care coordinator who ensures patients seek appropriate screening and follow-up care, especially if they suffer from chronic conditions.12

This model has now been extended to cover cancer care practices. Cigna now provides support to participating practices—in the form of financial incentives, data, and operational support—so they can ensure patients:

  • Have 24/7 access to a care provider
  • Have a go-to registered nurse (RN) oncology care coordinator
  • Are involved in treatment decisions with their oncologist
  • Can provide feedback on quality metrics, such as palliative care assessment and distress screening

Participating clinics have access to the following resources:

  1. Financial incentives, including a patient management fee and opportunity to partake of shared savings.
  2. Cigna’s patient database that will provide them with a daily inpatient admission report and a quarterly report on patient resource utilization.
  3. Significant operational support that includes, An oncology nonclinical navigator who supports partic&shy;ipating groups in the collaborative, acting as their single point of contact A case manager to support the RN A report on inpatient care within 24 hours A nationwide collaborative for participants to share and learn from best practices

According to the Advisory Board’s report, Cigna has collaborated with 3 oncology practices to launch Cigna Collaborative Care:

  • Virginia Cancer Institute, in Richmond, Virginia
  • Regional Cancer Care Associates, in Hackensack, New Jersey
  • Florida Cancer Specialists & Research Institute, in Fort Myers, Florida

Cigna announced in August that 3 other practices would be join&shy;ing the Collaborative13:

  • Northwest Georgia Oncology Centers, PC, in Atlanta, Georgia
  • Oncology Consultants, in Houston, Texas
  • Cedars-Sinai, in southern California

“We’ve had much success with our collaborative care arrange&shy;ments for large primary care physician groups. Now we’re apply&shy;ing that successful model—which includes a care coordinator employed by the medical practices and incentives that compen&shy;sate physicians for the value of the care they deliver—to drive similar improvements in quality and cost of cancer treatment,” said Bhuvana Sagar, MD, the Cigna medical director who provides clinical oversight for the company’s oncology collaborative care arrangements, in the press release.

A similar such initiative has been launched by Highmark Inc. Called the Highmark Cancer Collaborative, Highmark, which is an independent licensee of the Blue Cross Blue Shield Associa&shy;tion, has brought together the Alleghany Health Network Cancer Institute and the Johns Hopkins Kimmel Cancer Center to create and share best practices in cancer care. The Collaborative includes several different initiatives, all aimed to improve the standard of patient-centered care, such as:

  • Implementing standardized treatment pathways
  • Providing performance-based reimbursement for providers
  • Improving patient access to care by removing unnecessary ad&shy;ministrative barriers
  • Offering second opinions for patients based on the complexity of their disease
  • Arranging access to early-stage clinical trials

The patient-centric design of the model is obvious from the flexibil&shy;ity it offers to patients to seek care at alternative sites outside of the hospital if they are more convenient to patients and cost-effective.

“I believe we are unique in how we are integrating these compo&shy;nents together, centered around our members. Above all, we want patients to have confidence that they’re getting the best possible care,” according to Ginny Calega, MD, vice president of strategic clinical solutions at Highmark, in a statement. The model will ini&shy;tially include Highmark members in western Pennsylvania, with plans to expand to other Highmark markets.14

References

1. Wagner EH, Ludman EJ, Aiello Bowles EJ, et al. Nurse navigators in early cancer care: a random&shy;ized, controlled trial. J Clin Oncol. 2014;32(1):12-18. doi: 10.1200/JCO.2013.51.7359.

2. Appel SJ, Cleiment RJ. Identifying women at risk for hereditary breast and ovarian cancer syn&shy;drome utilizing breast care nurse navigation at mammography and imaging Centers. J Natl Black Nurses Assoc. 2015;26(2):17-26.

3. Oncology nurse navigator program. Spectrum Health Foundation website. https://give.spectrum&shy;health.org/joan-dallis-lightbox. Accessed September 21, 2016.

4. Hoffman AJ. Enhancing self-efficacy for optimized patient outcomes through the theory of symp&shy;tom self-management. Cancer Nurs. 2013;36(1):E16-E26. doi: 10.1097/NCC.0b013e31824a730a.

5. Family caregivers in cancer: roles and challenges (PDQ)—health professional version. National Cancer Institute website. https://www.cancer.gov/about-cancer/coping/family-friends/fami&shy;ly-caregivers-hp-pdq#link/_59_toc. Updated January 21, 2016. Accessed September 20, 2016.

6. Johnson DC, Mueller DE, Deal AM. Integrating patient preference into treatment decisions for men with prostate cancer at the point of care [published online June 23, 2016.]. J Urol. 2016. pii: S0022-5347(16)30743-1. doi: 10.1016/j.juro.2016.06.082.

7. Sprandio J. Oncology patient-centered medical home. Am J Manag Care. 2012;18(5 spec no. 2):SP98.

8. Page RD, Newcomer LN, Sprandio JD, McAneny BL. The patient-centered medical home in oncology: from concept to reality. ASCO University website. http://meetinglibrary.asco.org/con&shy;tent/11500082-156. Accessed September 20, 2016.

9. Coniglio D. Collaborative practice models and team-based care in oncology. J Oncol Pract. 2013;9(2):99-100. doi: 10.1200/JOP.2012.000859.

10. Henry E, Silva A, Tarlov E, et al. Delivering coordinated cancer care by building transactive mem&shy;ory in a team of teams [published online August 30, 2016]. J Oncol Pract. 2016. pii: JOPR013730.

11. Cigna Collaborative Care. Cigna website. http://www.cigna.com/newsroom/knowledge-center/ aco. Accessed September 21, 2016.

12. Miller B. Cigna’s Collaborative Care program is expanding—to cancer care. Advisory Board website. https://www.advisory.com/research/oncology-roundtable/oncology-rounds/2016/05/ cigna-collaborative-care. Published May 18, 2016. Accessed September 20, 2016.

13. Cigna collaborates with doctors to improve care for people fighting cancer [press release]. Bloomfield, CT: Cigna; August 25, 2016. http://www.cigna.com/newsroom/news-releases/2016/ pdf/cigna-collaborates-with-doctors-to-improve-care-for-people-fighting-cancer.pdf. Accessed September 20, 2016.

14. Highmark Cancer Collaborative launches in Pennsylvania [press release]. Pittsburgh, PA: Highmark Inc; March 30, 2016. https://www.highmark.com/hmk2/newsroom/2016/pr033016Can&shy;cerCollaborative.shtml. Accessed September 20, 2016.