Abstract: It was hypothesized that by introducing more intense supportive care and enhanced nurse navigation in high-acuity curable cancer patients, we could achieve the same results noted in patients with advanced disease. A clinical pathway was designed and implemented in 2016, called the Supportive Care of Oncology Patients (SCOOP). The scope of the program was limited to patients with potentially curable thoracic, colorectal, or head and neck malignancies. Major interventions included: (1) a nurse navigation electronic checklist; (2) a mandatory screening by the supportive and palliative care team during the multidisciplinary clinic visit; (3) flags in the inpatient information system that alerted in real time both the supportive care service and oncology services when patients were seen in the emergency room, admitted, and discharged; and (4) development of a better educational journal. This article provides an update on the program since its inception in November 2016. During the first 2 years of the program, nurse navigator compliance increased from 94% to 98%. Emergency department visits declined from 54% to 35%, admissions from 34% to 22%, and readmissions from 32% to 17%. Direct cost saving per patient was $1544.
Innumerable studies1-6 have demonstrated the positive impact of both effective nurse navigation and the early introduction of supportive care services for patients living with advanced cancer. Moreover, nurse navigation has also improved the experience of patients in the curative setting. A landmark randomized trial in advanced lung cancer patients5 demonstrated that the introduction of coordinated and standardized palliative care in these patients not only improved patient satisfaction and mean survival, but patient care costs were also reduced.
The Helen F Graham Cancer Center & Research Institute of the Christiana Care Health System is a busy cancer center with 3300 analytic cases a year and 14 disease-site multidisciplinary clinics (MDCs). In our previous approach to multidisciplinary oncology care, the patient would be seen by the 3 cardinal oncologic specialties—medical, surgical, and radiation—and a nurse navigator, who would be responsible for coordination of care with the ancillary services. Supportive care services, such as nutrition, psychosocial oncology, and social work, were not systematically present, nor was the palliative and medical support team. Discussion between the physicians and nurse navigator would determine further referrals to the support services. There were no electronic aids to navigation to assist the nurse navigators and no checkpoints or measures of accountability. There was no acuity testing or systematic referral to the medical support/palliative care service.
We hypothesized that by adding enhanced aids to navigation and a systematic approach to supportive care referrals we could improve the patient experience in curative patients akin to the results seen in patients with advanced cancer and achieve the Triple Aim of reduced costs, better medical care, and a better patient experience.7 Thus, the Supportive Care of Oncology Patients (SCOOP) pathway was born and implemented in the fall of 2016. Major interventions included: (1) a nurse navigation electronic checklist; (2) a mandatory screening by the supportive and palliative care team during the multidisciplinary clinic visit; (3) flags in the inpatient information system that alerted in real time both the supportive care service and oncology services when patients were seen in the emergency room, admitted, and discharged; and (4) development of a better educational journal.
The SCOOP pathway creation and implementation was published previously and included preliminary results from the first year.8 The present article provides an overview and update on the program evolution 29 months after implementation.
Initial Assessments and Establishment of Priorities
SCOOP is a clinical pathway designed to enhance navigation and increase the availability of supportive and palliative care to patients with curable cancers who are at high risk of clinical deterioration necessitating emergency department (ED) evaluation and/or admission. This large undertaking was only rendered possible because Christiana Care committed in 2016 to a formal structure of support for the 9 newly created service lines. With the encouragement of the institution, the Graham Cancer Center was able to put together an integrated practice team (IPT) and to select as members leaders from the different divisions of the Graham Cancer Center, including inpatient and outpatient nursing, nurse navigation, radiation and medical oncology, supportive and palliative care, and psychosocial oncology. Moreover, the IPT could and did draw on the expertise of system-wide essential services, including IT, Patient Experience, Organizational Excellence, Education, Data Measurement, and Communication teams.
The scope of the program is limited to patients with curative cancers of the head and neck, thorax, and colorectal/anal sites treated with combined modality chemotherapy and radiation and seen in the appropriate MDC. This group was selected because our preliminary data analysis revealed high rates of ED visits, admissions, and readmissions among these patients, and because resources limited the breadth of the program.
The IPT initially met biweekly and then monthly to analyze current processes from the time the patient presented in the MDC until one month after completion of their initial course of treatment. Examples of the barriers to excellent care that were noted included:
- Lack of standardized medical history forms;
- Redundant visits;
- Incomplete task performance by nurse navigators;
- Tardy or non-involvement of supportive and ancillary services;
- Poor ED communications;
- Poor communication about admissions and discharges resulting in poor hand offs between the hospitalists and oncologists;
- Admission of cancer patients to noncancer floors; and
- Insufficient patient education.
To identify opportunities with the greatest likelihood of positive effect on the patient, we developed an impact control matrix. The various opportunities received subjective scores for both their impact and the ability to effect a change. Those that received highest combined total impact control scores were the greatest focus of the IPT. These included:
- Ensuring screening of our entire cohort at the time of initial MDC visit by a member of the supportive and palliative care team;
- Developing an electronic checklist for nurse navigation;
- Flagging patients at the time of ED visit, admission, or discharge to facilitate hand offs;
- All ancillary services such as psychosocial oncology, nutrition, social work, and dentistry to be contacted automatically unless the patient opts out at the time of the MDC visit; and
- Developing an educational journal for patients to help them take ownership of their care and reduce their anxiety levels.
Building and Effecting the Clinical Pathway
Once priorities were identified, responsibilities were assigned among the IPT members. Ensuring that all the eligible patients participated in the program was an educational challenge. In some cases, navigators failed to note that the patients were eligible, but, over time, it became evident that patients did not participate at the anticipated rate due to poor dissemination of information to providers who did not perceive the advantage of and were used to bypassing the MDCs. Those patients who were eligible but did not enter the SCOOP pathway became a convenient contemporary control group for our metrics.
During the first 6 months, participation was only 50% but improved to 85% in the next year after substantial educational efforts were made with the physician and nursing staff. In addition, during this time period a “re-entry” pathway was developed with the radiation oncology nursing staff, who identified patients who were eligible and were not on the list of SCOOP patients. These patients were then referred back to the MDC to meet with the entirety of the support staff (but not necessarily the physicians) at the same time.
We developed a detailed checklist for the nurse navigators that specified prescribed communication dates with the patients, ensured that patients kept appointment visits, and assessed unmet needs.8 The checklist was tailored to the specific needs of each MDC and the navigators’ checklists were prepopulated with tasks. For instance, the Head and Neck MDC patients’ checklist included: appointments/referrals to social work, nutrition, physician appointments, dentistry, diagnostic testing, supportive care, and speech and swallowing. In addition, it included a mandatory plan of care discussion with the navigator and mandatory periodic communication with the patient or family. Those tasks deemed unnecessary by the navigator were removed from the checklist. Because the checklists were prepopulated, the need for navigators to remember each referral was obviated, making omission less likely, while the ability to opt out of tasks reduced redundancy.
We implemented the checklist using a platform intended for population health called Aerial (Medecision Inc) that integrates with our electronic health record (EHR).9 The Christiana Care IT team collaborated with the SCOOP team to adapt the platform to ensure timely completion of tasks, improve care coordination, and prevent gaps. The checklist provided collaborative communication from the onset and generated automatic tasks at specified time intervals based on the date of clinical pathway creation, treatment start, and completion dates.
The checklist is automatically displayed and updated daily, avoiding the hazards of manual entry. Entering patient characteristics in a drop-down menu initiates the checklist. Following completion of the required fields, the software generates patient-specific and a time-driven series of tasks that the navigators must complete. These tasks may be delegated to other providers, but the system still alerts the navigator whether the tasks remain pending or have been completed. The tasks stay on the list until they have been completed. The software provides a daily task list, functioning as a reminder to the navigators of the task status.
Because the IT adaptation of Aerial communicates easily with the Christiana Care information system, the navigators (as well as the oncologists and supportive care team) are provided with alerts indicating ED visits, admission, or discharges. By tasking the navigators with reviewing the discharge data and communicating with the patient following discharge, the pathway reduces risks of inadequate hand offs and patient misunderstandings and facilitates a smoother transition from the hospitalists to outpatient oncology, where appropriate referrals can be made by the navigator.
Early Introduction of Supportive Care
The supportive care team provided a member of the palliative and medical support team to all the eligible site-specific MDCs—thoracic, head and neck, and colorectal—as well as the medical support MDC. The medical support and palliative care physicians or advanced practice nurses screened all patients and their records for acuity and, based on the results, would either consult immediately with the patient, refer them for nonurgent consult or, in the more robust individual, provide the patient with contact information and explanation of purpose. Moreover, the palliative and supportive services were able to maintain continuity with the patients during ED visits and admission as they were alerted of these events by alert flags in the EHR.
Our preliminary current state analysis of patient education (derived from patient feedback data) showed our written materials to be lacking, and our impact control analysis indicated that providing a more directed written education for the patients would assist substantially in augmenting navigation. Thus, we redesigned our brochure (Figure 1) to mirror the patient advice we received.