Abstract: Clearview Cancer Institute is a private, community practice participating in the Oncology Care Model, an innovative pilot project sponsored by the Center for Medicare and Medicaid Innovation. Over the last 2 years, the practice has worked to implement nursing triage pathways in an effort to streamline patient assessments and reduce emergency department utilization rates. As a follow up to the previously published article “A Community Practice Perspective on Implementation of the Oncology Care Model,” Clearview Cancer Institute provides a deep dive into the process for creating, implementing, and maintaining these pathways, as well as results associated with program implementation.
Since 1985, Clearview Cancer Institute (CCI) has served adult hematology and oncology patients in north Alabama. CCI is a private, physician-owned, community practice with six full-service locations, two of which are in Huntsville, with others in surrounding areas including Decatur, Florence, Cullman, and Jasper. CCI also has three satellite clinics in Athens, Madison, and Scottsboro that are available to serve patients for office visits on select days of the week. The practice is home to 17 physicians and 18 advanced practice providers. At the full-service locations, CCI offers outpatient therapy, diagnostic imaging, genetic and genomic testing and counseling, lung cancer screenings, a specialty pharmacy, autologous stem cell transplant, physical therapy, and clinical trials, including phase 1 trials.
Oncology Care Model (OCM) Programming at CCI
After being accepted as an OCM practice1 in April 2016, CCI identified areas for new programming as well as action items to address process improvement and impact patient outcomes.
New programming action items included: (1) identification of OCM eligible patients to gather data and bill MEOS payments; (2) implementation of the 13-point Institute of Medicine care plan form and data collection processes2; (3)creation of nurse navigator triage pathways to facilitate reduction in emergency department (ED) use and hospital admission rates; and (4) analysis and interpretation of claims data. Process alterations for existing programming included: (1) data collection and analysis for quality measures reporting; (2) enhanced depression screening; and (3) internal clinical pathway compliance and tracking.
After addressing other new programming action items, CCI began the process of nursing triage pathways implementation in June of 2017. Since then, a great focus for CCI has been the creation and maintenance of the nursing triage pathways, as well as tracking of outcomes associated with program implementation.
As a follow up to the previously published article “A Community Practice Perspective on Implementation of the Oncology Care Model,”3 this article explains and comments on the process for creating, implementing, and maintaining these pathways, as well as results associated with program implementation.
Primary Nurse Model and Triage Process
CCI utilizes nurse navigators in a primary nurse model.4 At this time, CCI employs 15 total nurse navigators, 14 of whom are assigned to a specific provider team and 1 of whom will float between provider teams and help cover when other navigators are out of the office. Twelve of these navigators are assigned to one provider team, which consists of a physician, advance practice provider (APP), and medical assistant. The remaining three navigators, including the float navigator, are shared between newly hired or lower patient volume physician teams.
Nurse navigators are available to address symptom management and triage calls Monday through Friday from 8 am to 5 pm. After 5 pm, symptom management and triage calls roll to an assigned nurse through 6 pm. Calls after 6 pm Monday through Friday are directed to the provider on-call. Daytime calls on Saturday and Sundays are addressed first by the nurse navigator on call for that weekend, and then directed to the provider as needed. This allows clinical personnel to work to the top of their license while also supporting patients with greater clinician availability after hours and on the weekends (Figure 1).
Calls are directed through operators at the main location in Huntsville. Upon receiving a clinical call, a telephone operator creates a triage document in OncoEM© describing the patient’s concerns. This document is forwarded through the inbox system in OncoEMR to the appropriate nurse navigator. The nurse navigator is able to see the patient’s basic demographic information, reason for the call, and time of the call, in order to triage calls in his or her inbox. When the nurse navigator calls the patient back, he or she is able to open the forwarded note and complete the appropriate documentation.
Decision to Create Symptom Management and Triage Pathways
In March 2017, the OCM Learning System Team, a group working within OCM through the Center for Medicare and Medicaid Innovation, published “OCM Case Study #1: Reducing Potentially Avoidable Hospitalizations and Emergency Department Utilization.”5 In this case study, five OCM participants shared best practices for impacting these metrics. The study concluded that offering same-day appointments; establishing extended hours; providing access to outpatient symptom management; and assessing, responding, and alleviating patient distress were areas for action and impact.5 The resources and toolkits provided in the case study allowed CCI to further research evidence-based triage processes.
In an effort to assist nurse navigators in practicing to the top of their training scope, as well as to reduce ED admissions, the OCM team at CCI sought feedback from key stakeholders in group and one-on-one meetings to discuss nursing triage pathways. Administration and nursing management were extremely supportive of the idea to improve assessments with hopes of impacting patient outcomes. Nurse navigators were more skeptical of the idea due to changes in workflow and day-to-day practice patterns. Several software platforms were introduced as potential solutions for symptom management and triage pathway implementation. Ultimately, none of the platforms were selected due to electronic health record (EHR) integration issues and concerns about the navigators utilizing two platforms simultaneously. Many platforms included using a separate system prior to integration in the EHR, which resulted in negative feedback from the nurse navigators. CCI ultimately decided on having internal pathways created by nurses on the OCM team.
Creating Internal Symptom Management and Triage Pathways
Pathways were derived from two main resources: the book Telephone Triage for Oncology Nurses6 published by the Oncology Nursing Society (ONS) and the Remote Symptom Practice Guides for Adults on Cancer Treatments,7 which was developed by the Pan-Canadian Oncology Symptom Triage and Remote Support Team. Initially, the following pathways were created for use: diarrhea, nausea and vomiting, fatigue, bleeding, febrile neutropenia, mouth sores/stomatitis, and dyspnea/breathlessness. These pathways were chosen because the items represented global issues highlighted by OCM case studies and were also reflected in CCI’s claims data received through the OCM program reports. In early versions, each triage pathway included a flow chart or decision tree to arrive at the final clinical decision based on the patient’s symptoms and also includes home care instructions for additional education when needed. These pathways were piloted by two senior nurse navigators in May 2017. Feedback from the nurse navigators was positive, noting that the pathways were a great resource, as they would reduce time spent asking for physician or APP guidance and would assist in additional patient education efforts.
After positive feedback in formal meetings and one-on-one meetings with navigators and nursing administration, the pathways were approved for use by the Physician Advisory Committee. In June 2017, these pathways were rolled out to the team of nurse navigators. Paper (Figure 2) and electronic PDF copies of the pathways were provided to nurse navigators on internal storage sites. Nurse navigators were asked to document and reference pathway use in their OncoEMR triage notes when appropriate for reported patient symptoms. Subsequent review of nurse navigator documentation through December 2017 revealed that the triage pathways were not being documented or, when documented, were not being utilized consistently or correctly. This discovery refocused planning and re-implementation to include: additional review of outside software availability for implementing, utilizing, and tracking triage pathways; investigating capability within OncoEMR to build more intuitive text notes, including grading scales and prompting; and additional revision of triage pathways to better reflect current patient needs and nurse navigator feedback.
Outside Software Availability
Once again, third-party vendors were contacted to provide demonstrations of software functionality. These demonstrations were conducted for administration, nursing management, and nurse navigator staff. Feedback remained consistent with previous demonstrations and included concerns and complaints about integration issues, utilizing two platforms simultaneously, and an increase in workload from a dual documentation standpoint. After one demonstration, some nurse navigators suggested integrating the current paper pathways into OncoEMR. It was agreed among administration, nursing management, and the nurse navigators that this would be the best option for moving forward with standard triage and symptom management processes.
Implementation of Symptom Management and Triage Pathways Into OncoEMR
In April 2018, a staff member began building two OncoForms (structured document forms in OncoEMR) for symptom management and triage pathways (Image 1). The building of forms was completed between other projects and responsibilities, and time was spent throughout the month to complete the build. One form was designated to address true symptom management and triage phone calls for clinical situations, and the other form was meant to capture calls for refill requests, rescheduling requests, and requests for results. The symptom management form included tabs outlining the reason for the call, Health Insurance Portability and Accountability Act verification, pain, nausea/vomiting, diarrhea, fatigue, mucositis/stomatitis, bleeding, febrile neutropenia, and dyspnea/breathlessness. Each tab includes a Common Terminology Criteria for Adverse Events grading scale, guided assessment items, relevant medication and prescription documentation, and nursing action and education based on the symptom assessment. Where applicable, each tab also includes guidance about when certain symptoms do warrant a referral to the ED, when symptoms can be addressed in the clinic, and when symptoms should be addressed with home care instructions and education. The clinical form also included an open text section for other clinical issues, and the nurse navigator can address other items not related to one of the main pathway items.
The forms were completed in the system and nurse navigators were trained in late April 2018; in early May 2018, forms were formally implemented across all clinics. Training included a group lunch meeting lasting one hour, and one-on-one time was spent with navigators over the next few weeks of roll out. At their annual performance reviews in July 2018, nurse navigators were given new performance metrics to achieve throughout the following year. One performance metric included the appropriate use and documentation in new triage pathways forms. This performance metric is directly tied to potential for a raise and/or bonus at the next annual review.
Pathways Maintenance and Nurse Navigator Pathways Committee
After implementation of the forms, both positive and negative feedback were received. Several seasoned navigators believed the form was difficult to use and did not feel they needed assistance with assessing their patients. Other navigators complimented the ease of use and convenience in streamlined assessments and documentation. Largely, there were regular requests for updates to the forms, such as adding more options for documentation as well as requests to create pathways for other symptom management issues. This feedback from the nurse navigators led to merging the two forms into one form in February 2019. As of the printing of this article, pathways for constipation, skin irritation, and fatigue or diarrhea related to immunotherapy have been created and added to the forms. Additionally, tabs for vital signs and medications were also incorporated into the form per suggestions from the nurse navigators.
Because of continued feedback regarding the symptom management and triage pathways form, a Nurse Navigator Pathways Committee was formed. This group consists of four nurse navigators across three clinic locations who meet once a quarter. Their objectives are to review current symptom management and triage pathways and create new symptom management and triage pathways for implementation. Two main pathways of focus from this committee include triaging for urinary tract infections and triaging mental health and distress.
Tracking and Results
Tracking the reasons and outcomes of patient calls has become easier since integration of the symptom management and triage pathways in OncoEMR. Each pathway has structured data fields that allow data analysts to follow the patient trajectory and outcomes of the call through running reports in OncoEMR and exporting the data for aggregation.
Since implementation of the OncoForm symptom management and triage pathways, many metrics point to successful implementation and appropriate use. The first metric pointing to success includes the documentation of add-on provider visits and add-on visits for fluids. From June 2018 to June 2019, CCI tracked 4020 calls tied to applicable clinical pathways and logged 501 add-on provider visits and 410 add-on visits for fluids. As this number has increased, CCI has worked to create additional add-on appointments by utilizing float APPs and has also rearranged treatment areas to ensure that chairs are available for fluid administration and other infusion needs. At this time, clinic hours have not been expanded as a result of add-on appointment needs.
Data from quarterly feedback reports as well as 6-month performance periods (PP) also supports success in reducing ED use as a direct result of symptom management and triage pathways. Based on data from PP1 to PP3, ED use decreased 11.6% for OCM attributed patients. Although complete data is not available at this time, projections for PP4 continue to demonstrate ED rates lower than baseline, at about a 4% reduction. From nonrisk adjusted data in the quarterly feedback reports, CCI has consistently reduced ED use across all 11 quarters in OCM but has experienced the steadiest decline from quarters 6 through 10, which correlates directly with implementation of these pathways.
Future Practice Implications and Conclusion
As CCI continues to serve patients and seek opportunities to impact care, the need to continue revising and enhancing the pathways is anticipated. The current plan is to utilize the Nurse Navigator Pathways Committee to address many of these needs, as these employees are on the front lines of addressing patient calls and are key stakeholders in using this technology. CCI also hopes to investigate inpatient utilization and determine actions that can be taken to reduce admissions during clinic hours. dditionally, CCI looks forward to a continued partnership with Flatiron in finding new and innovative solutions to impact our nursing triage documentation and processes inside OncoEMR.
1. Centers for Medicare & Medicaid Services. Oncology Care Model. https://innovation.cms.gov/initiatives/oncology-care/. Updated September 11, 2019. Accessed October 24, 2019.
2. Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine. Levit L, Balogh E, Nass S, et al, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: National Academies Press (US); 2013.
3. Fraley AM. A community practice perspective on implementation of the Oncology Care Model. J Clin Pathways. 2018;4(4):40-45. doi:10.25270/jcp.2018.05.00015
4 Understanding the primary nursing care model [blog]. Healthcare Management & Administration Blog. https://www.healthstream.com/resources/blog/blog/2019/08/29/understanding-the-primary-nursing-care-model. Published August 29, 2019. Accessed November 4, 2019.
5. Centers for Medicare & Medicaid Services. Oncology Care Model: Key drivers and change package. https://innovation.cms.gov/Files/x/ocm-keydrivers-changepkg.pdf. Published August 4, 2016. Revised June 3, 2019. Accessed October 24, 2019.
6. Hickey M, Newton S, eds. Telephone Triage for Oncology Nurses. Pittsburgh, PA: Oncology Nursing Society; 2012.
7. Stacey D. Remote Symptom Practice Guides for Adults on Cancer Treatments. https://ktcanada.ohri.ca/costars/Research/docs/COSTaRS_Pocket_Guide_March2016.pdf. Ottawa, Ontario: University of Ottawa School of Nursing and the Ottawa Hospital Research Institute; March 2016. Accessed October 24, 2019. https://www.healthstream.com/resources/blog/blog/2019/08/29/understanding-the-primary-nursing-care-model. Accessed October 24, 2019.