Oncology Practice Management, Navigation, & Advocacy Day Abstracts

How to Implement Oncology Disease Site Specific Multidisciplinary Centers (MDCs)
Kelley D. Simpson and Tricia Strusowski, RN, MS

Patients, families and their caregivers are insisting on multidisciplinary care when they are diagnosed with cancer. Multidisciplinary care is a treatment planning approach that includes a surgeon, medical oncologist and radiation oncologist along with the cancer center support staff. The support staff could include a navigator, social worker, genetic counselor, dietitian and others as the specific disease site stipulates. The team meets with the patient and their family, reviews their test results, imaging, medical history and creates a plan of care based on national guidelines, diagnosis and stage of disease. The goals are to increase communication among the healthcare team, create an individualized treatment plan based on national guidelines, increase clinical trial enrollment, reduce time to treatment and avoid treatment breaks, and provide patient centered care by including the patient in the decision making process. The primary benefits to MDC care are:

• To provide “one stop shopping” for the patient and their family;
• To enhance the patient experience and informed decision making;
• To elevate the accuracy of treatment plan by increasing discussion by physician and support staff; and,
• To incorporate screening for barriers to care and psychosocial distress and coordinate with the appropriate support staff.

The treatment plan is highly coordinated and the patients value their participation in the planning phase of their care. The patient leaves with a written summary and an assigned nurse navigator to ensure coordination of their appointments and coordinate support services.

There are many details when implementing multidisciplinary programs and clinics; this is where the process can become overwhelming for a cancer program. The models and infrastructure of the multidisciplinary centers can vary based on the physical layout of the cancer center and availability of the physicians and support staff. Patient referrals and workflow before, during and after the MDC appointment must be meticulous and all staff must have a full understanding of their roles and responsibilities. The responsibilities must be completed in a specific order to ensure a successful patient visit—a couple of examples are gathering correct medical records, imaging and tests as well as insurance verification and authorization with a full review with the patient is required.

The day of the MDC visit may vary based on the cancer disease site, volume of patient appointments and physician interactions. Although the documentation and flow remain the same, the dynamics of the team may differ. High volume disease site MDCs will need to function very differently than low volume sites, with great options to enhance the logistics and patient flow while still ensuring an outstanding patient experience.

After the MDC appointment there is still a tremendous amount of work to be accomplished. The physician orders must be completed, dictation and billing in compliance with the financial department and follow-up treatment summary sent to the referring physician. The role of the navigator is vital to effectively review with the patient the treatment plan, coordinate appointments and answer any outstanding questions.

The overall multidisciplinary center experience for the patient, their family, physicians and the support staff is superb, providing high quality coordinated care. This presentation will provide the details to ensure a successful implementation of multidisciplinary centers.

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Navigation: Patient Experience, Clinical and Financial Outcomes
Kelley D. Simpson and Tricia Strusowski, RN, MS

Robust navigation programs across the country include outreach/screening, treatment and survivorship navigators. The Commission on Cancer (CoC) has outlined new standards to be phased in for 2015 on the navigation process, including a community needs assessment, psychosocial distress screening and the survivorship care plan. The role of the navigator is to assess the patient’s and family’s understanding of their diagnosis and treatment, assess and remove barriers, provide psychosocial screening, and coordinate support staff and appropriate resources.

The first step in the process is to complete a thorough community needs assessment to understand patients in the community and their specific needs and barriers to care. This creates a strong foundation for the navigation program across the entire continuum of care. The navigation program must be created and modified to meet the needs of the patient through the community needs assessment. The navigation matrix created by the National Comprehensive Cancer Center Program (NCCCP) Navigation Networking Committee is another excellent tool to utilize to incorporate all the essential components into a program. The matrix categorizes 16 elements with levels 1 through 5. Every navigation program is unique and the role of the matrix is not to gauge one program against another but to provide guidance to create a stronger program. Some of the elements include key stakeholders, acuity systems, reporting/quality measures, focus on disparities, clinical trials, etc. As the navigation program is built patient experience, clinical and financial outcomes should be a high priority, this will ensure the patient is always in the forefront and high clinical standards will help ensure financial strength.

The Institute of Medicine shared some staggering outcomes specific to the patient experience in oncology, the number one statement from cancer patients was “listen to me.” Other comments included…“tell me the full truth about my diagnosis,” “tell me about the risks.” Cost concerns were also a major worry as was not fully understanding all the options available for their cancer treatment. Patients want to participate in the care planning sessions with their health care team to make informed decisions. There are excellent measures to ensure a superb patient experience such as:

• Measure outcomes/interventions related to barriers to care and distress screening
• Report outreach/navigation of disparate populations
• Patient experience survey
• Quality of Life survey—Cancer Survivor version
• Patient education packets for surgery
• Caregiver toolkit
• Patient appointment checklist
• Survival toolkits for families
• Tele-monitoring program for patients
• Complementary and alternative therapies/outcomes
• Cancer disease site specific rehabilitation programs.

Measuring clinical outcomes elevates the standard of oncology care. Every navigation program needs to incorporate research and quality measures into its foundation. Some examples are:

• Clinical care in concordance with National Comprehensive Cancer Network (NCCN) or other national guidelines
• Tumor conference audits, review of recommendations, NCCN guidelines and stage documentation
  
• Time of diagnosis to first treatment modality
• Survivorship surveillance plan compliance/monitoring
• Monitoring of late/long term effects of cancer treatment
• Creating standing order sets by cancer disease site for multidisciplinary teams
• Clinical trial education and referrals to Cancer Research
• Disease site specific clinical initiatives, example, measuring head and neck cancer patient referrals to dentist for dental clearance prior to initiating treatment
• Oncology rehabilitation programs by cancer disease site.

Financial outcomes are very important for maintaining a navigation program. Navigation programs can be very expensive and return on investment is critical. Some financial outcomes to measure include:

• Decrease emergency room visits and re-admissions
• Medication reconciliation program
• Self-pay patients assessed and referred to Medicare or Medicaid
• Medical home for oncology patient
• Length of stay reduction, partner with inpatient oncology unit
• Downstream revenue for imaging, tests, procedures
• Referrals to revenue generating support services
• Patient retention rates/decrease outmigration
• Care in concordance with NCCN or other national guidelines
• Targeting primary care physician/specialist for referrals to specific disease site cancers, i.e. screening for lung cancer, referrals for navigation/support services.

In conclusion navigation, patient experience and outcomes are imperative for a state of the art cancer program. This presentation will provide ideas and examples to further enhance conference attendees’ navigation programs and or introduce new concepts for those preparing to institute a new program in alignment with CoC 2015 standards.