The term “patient-centered care” took on new importance for oncologists this fall when an Institute of Medicine committee finished its investigation of cancer care in America. The executive summary of its report starts off with this: “The committee concludes that the cancer care delivery system is in crisis. Care often is not patient-centered” (OT 10/10/13).
Definitions for patient-centered care are all over the board, but oncologists who want accreditation from the American College of Surgeons Commission on Cancer (CoC) must focus on three concepts:
- Patient navigation;
- Psychosocial distress screening; and
- Survivorship care planning.
Beginning in 2015, the CoC will include all three in its accreditation reviews, although it has not provided guidance on how the patient-centered practices should be implemented.
“I think the Commission on Cancer recognizes the importance of patient-centered care and the importance for these programs, but they also realize that clinical practice, in reality, has a lot of constraints,” said Mandi Pratt-Chapman, MA, Associate Director of the George Washington University Cancer Institute (GWCI). “To be too prescriptive would potentially not result in the best outcomes for patients, since we are still figuring out the best way to deliver patient-centered care.”
Against that backdrop, she presented information at the Association of Community Cancer Centers Oncology Cancer Conference about what GWCI is doing to meet the CoC standards, an effort for which the institute won one of ACCC's Innovator Awards this year. The awards, sponsored by GE Healthcare, recognize “pioneering strategies for the effective delivery of cancer care in the community setting.”
To meet the CoC standard, cancer programs must assess the needs of their communities and develop a navigation process to address disparities, barriers, or gaps in care.
Navigation programs for cancer patients have become common in recent years (bit.ly/OT-PtNavigation), and evidence that navigation is effective in helping patients is beginning to accrue. Among other data, a study involving more than 2,600 women examined for breast cancer over a five-year period found that navigated patients received a diagnosis 17 days earlier, on average, than non-navigated patients (Cancer Epidemiol Biomarkers Prev 2012; 21:1655-1663).
But navigation programs vary widely, and little is known about what elements are essential to success, Pratt-Chapman noted. GWCI introduced navigation with a single navigator many years ago and has grown the program with its clinical partners the GW Hospital and the GW Medical Faculty Associates, to now include:
- A radiology nurse navigator responsible for patient education;
- A radiology navigator who works with Spanish-speaking patients to reduce any administrative, logistic; or transportation barriers that might impede their care;
- A hematology oncology social worker who provides psychosocial support;
- A breast care center navigator who serves as the primary patient contact for any patient getting breast cancer surgery;
- A navigator located in urology and radiation oncology who works primarily with prostate cancer and head and neck cancer patients; and
- A survivorship navigator.
GWCI continues to refine its navigation services, Pratt-Chapman noted. A navigation supervisor was hired to standardize navigation processes and collect data that can be used to monitor the quality of the services.
Psychosocial Distress Screening
The CoC standard requires cancer programs to establish a process to monitor distress at a pivotal point of care, but it does not dictate that time period or the screening method to be used.
GWCI created a psychosocial distress working group—patient navigators and the navigation supervisor, the cancer center's social worker, and members of the nursing staff—to determine how to meet the CoC standard.
“There was some anxiety, frankly, about rolling this out, because physicians are constantly being asked to do more with less, so there is a lot of pressure on providers,” she said. “The fear was if we roll out this distress screening process and find that many people are distressed, what do we do about it?”
The team proposed screening patients at up to four time points during their care: before surgery, before chemotherapy, before radiation, and when treatments were completed. Designated staff members—an infusion nurse conducts the pre-chemotherapy screen, while the breast cancer navigator does the pre-surgery screen—use a National Comprehensive Cancer Network screening tool to rank the patient's distress level on a 10-point scale.
“You need to make sure you have a plan of what you're going to do with each score, and who you're going to send patients to, based on the score and the problem,” she said.
The GWCI team developed a triage protocol: Individuals who report low distress are referred to support groups and other resources and encouraged to contact their patient navigator if they have concerns. High distress scores trigger a multidisciplinary response with the screener taking the lead. If the patient reported practical concerns, such as insurance or transportation, his or her navigator is assigned to address them. Patients who report emotional concerns are referred to the social worker or a psychiatric counseling program specifically for cancer patients, and patients with physical problems are referred to a nurse or physician.
“We haven't had an unmanageable number of individuals in distress,” Pratt-Chapman said. “We have identified problems sooner and are able to address them before they become unmanageable.”
To date, distress screening has been launched in GWCI's division of hematology oncology and breast care center, with radiation oncology and other clinical areas scheduled for the future.
The CoC standard requires a plan provided by the principal providers in charge of a patient's care, with input from other members of the care team. Given to the patient when treatment is complete, the plan must contain the record of the patient's care as well as disease characteristics and a follow-up care plan.
GWCI opened a clinic for adult survivors of pediatric cancer in 2010 in collaboration with the GW physicians group and Children's National Medical Center. Patients who visit the clinic see an internal medicine physician, a nurse practitioner, a patient navigator, and a dietitian.
A similar clinic was created last year for patients who had been treated for adult-onset cancers. “The whole point is really to help educate survivors about their treatment history and the potential effects and risks that they might experience as a result of their treatment,” Pratt-Chapman said. “And also how they can promote their own wellness through diet changes or physical activity, which is why the dietitian consultation is very popular.”
To respond to the CoC requirements, GWCI adapted a survivorship care plan template created by Memorial Sloan-Kettering Cancer Center that provides basic information about the patient's treatment schedule and dosages, known late effects of those therapies, a follow-up plan, and a visit schedule. (The template is available at smhs.gwu.edu/gwci/sites/gwci/files/TACSCP.pdf.)
Pratt-Chapman noted that GWCI has not yet determined how the oncology team—the principal providers in charge of a patient's treatment, as per the CoC rules—can develop and deliver the plans to every patient.
“It takes a lot of time to compile these plans and to deliver them, and you can't just hand someone a piece of paper. There needs to be education about what you're telling a patient, so that they understand exactly what you are saying and what they should be doing next.”
The National Cancer Survivorship Resource Center, a collaboration between the American Cancer Society and the GWCI with funding from the Centers for Disease Control and Prevention, offers support to help survivorship programs get started. A free Guide for Delivering Quality Survivorship Care is available online at cancersurvivorshipcentereducation.org.
The resource center also offers a free online education program targeted to general medicine physicians, geriatricians, and other primary care providers who care for cancer survivors. Modules currently online include:
- The Current State of Survivorship Care and the Role of Primary Care Providers;
- Late Effects of Cancer and its Treatments: Managing Comorbidities and Coordinating with Specialty Providers;
- Late Effects of Cancer and its Treatment: Meeting the Psychosocial Health Care Needs of Survivors;
- The Importance of Prevention in Cancer Survivorship: Empowering Survivors to Live Well; and
- A Team Approach: Survivorship Care Coordination.
Part of a continuing series on innovations in oncology practice. A collection of the series to date is available at http://bit.ly/OT-Innovations