Delaware’s ChristianaCare Embeds PCP Care Within the Cancer Center

With patients who have cancer living longer, building connections between the oncologist and the primary care provider (PCP) who will take care of health needs beyond care is more important than ever.

But what happens is the patient with cancer has no PCP? This was the challenge ChristianaCare’s Helen F. Graham Cancer Center and Research Institute, based in Newark, Delaware, took up when it embedded PCP care within the cancer center, both to provide for immediate needs of the center’s patients and to connect them with primary care for the future.

ChristianaCare is the dominant health care system in Delaware, the nation’s second-smallest state, with 3 hospitals including a Level 1 trauma center. But, as Debra Delaney, MSN, FNP-BC, primary care nurse practitioner, explained Thursday during the Association of Community Cancer Center 39th National Oncology Conference, Delaware’s smallness can still mean long drives for some of residents in the most rural stretches of the state. ChristianaCare’s program was among the winners of the 2022 ACCC Innovator Awards.

And, Delaware’s shortage of PCPs is acute, meaning that ChristianaCare was seeing more and more patients with cancer who had no family practice to rely on outside of cancer treatment. An estimated 15% of the cancer center’s gynecological oncology patients had no PCP, for example. That meant no other physician to help manage comorbidities or deal with care coordination, with led to treatment delays and unnecessary stress.

When the idea was presented to Delaney to embed PCP care at the cancer center, she knew it made perfect sense. “Everyone should have a primary care provider, but we know that’s not the case,” she said.

The launch of PCP care in the cancer center took flight in January 2021, with a small unit of 5 beds, advanced practice clinicians and a registered nurse and a medical office assistant. Delaney also sees some patients via telehealth. Within 6 months there were 70 patients, she said.

In a year’s time, ChristianaCare has learned a lot. “It’s a constantly evolving practice,” Delaney explained. The original plan was to set up a referral as soon as treatment ended, but the cancer center soon found that more challenging than expected. Patients might end up going to the emergency department (ED) if they don’t have a PCP; if suspicious mass is found or a new issue arises, they are referred back. Patients who need presurgical evaluations and have no PCP are also referred.

And there are advantages to being embedded in the cancer center, Delaney said. Access to each patient’s cancer care records is a huge advantage, as she can see all the notes—she noted how being part of the cancer center offered access to information that prevented prescribing a diarrhea medication that would have interfered with a patient’s clinical trial. In another case, the oncologist had explained which medications were contraindicated with cancer therapies, including one that was not obvious.

Still, it’s part of Delaney’s job to ultimately connect patients with local PCPs when possible, and she spoke of those successes, too. She manages the timing of the handoff back to a local provider and helps patients find one when possible. “If you've got patients travel over 2 hours from downstate…they prefer to have a primary care provider that are closer to their home, which I can certainly help with,” she said.

When these handoffs occur, Delaney ensures that the new provider has all the patient’s data and fully understands the case.

And there are a few patients who resist a transfer, even when it’s in their interest. Delaney reviewed the case of a veteran who found the VA very complex, but the cancer center worked with him on a transition so he could access a host of social needs for which he was eligible.

“I sat down with him, and we had a long talk about this,” she said. When the veteran was able to make the transition, “he was very grateful.”

Oral oncolytic delivery. Baptist Health South Florida, Miami Cancer Institute,had a problem.The rise of oral oncolytics in cancer care, staffing challenges, COVID-19, and processes that clinicians used to manage prior approval challenges had all combined to create problems with patient medication education.

An audit had revealed a major gap: Miami Cancer Institute offered high quality education, but it wasn’t always timely. With problems such as white bagging increasing, only about 60% of patients received a prescription and an education session on the same visit. That mean there was a risk some would start taking oral oncolytics before their education session.

Morgan Nestingen, MSN, APRN, AGCNS-BC, NEA-BC, OCN, ONN-CG, director of nursing for Patient Intake and Navigation Services, explained both the commitment and the process that led to same-day education, which earned Miami Cancer Institute a 2022 ACCC Innovator Award.

Nestingen admitted that some were skeptical that the goal of same day education delivery could be achieved. Prior authorization had bedeviled physicians—and it was driving prescribing practices, she said.

The plan involved creation of a dashboard that would measure compliance by capturing orders on the EHR and following through to ensure that navigators and nurses had the opportunity to complete all necessary steps to educate patients on the medication they would be taking while they were on site. Innovative technology allowed for electronic consent. On-call nursing support is part of the equation. It took lots of 7 a.m. Friday meetings, support from IT, and “a lot of microadjustments” to make minor changes that added up to a big shift, Nestingen said.

By the second month of the project, same-day compliance had reached 90%; by the end of month 3, it had reached 95%. The project is now heading into a second phase, she said. The lesson, Nestingen said, is that “Technology can enhance traditional approaches to in-person care coordination.”