Transitions in Cancer Care - Moving From Crisis Intervention to Care Planning and Management

Although the US healthcare landscape appears to be shifting yet again with a new Congress and administration vowing to replace the Affordable Care Act 7 years after its passage, at least one trend remains stable: the healthcare sector will continue to shift towards becoming more patient-centered, while emphasizing quality and improved, measurable outcomes of the population served.

Further, the rise of new value-based payment models that prioritize quality over quantity of services will lead to new benchmarks for care. This, in turn, is driving the redesign of our healthcare delivery model, transforming it into one that puts patients and families at the center of care management. Increasingly, providers are beginning to organize into integrated practice units (IPUs) and integrated care delivery systems that shift providers away from their traditional role as siloed institutions and towards a more cohesive network of care delivery.¹

These trends are both good for the patient and good for the payer, as providers who are implementing new models are seeing and experiencing on the front lines of care.

Nowhere could this trend be more evident than in the oncology sector, where a major reorganization in the way cancer treatment is delivered is currently underway. Patients and families have become essential voices in decisions on care delivery and the care experience. Embracing this new model of team-based care, in which responsibility for a patient’s well-being is shared among clinical and nonclinical staff alike, will lead to more integrated, interdisciplinary units while improving quality and lowering costs across the spectrum.

As we fully embrace this new model of oncology care delivery, it is crucial that communication and information sharing among care providers continue to develop, while workflows between different segments of the care cycle remain integrated. Three key areas lie at the forefront of this shift:

• Prescription and delivery of palliative care
• An increasingly important role for clinical staff in navigating a patient through the treatment process
• The ever-increasing importance of interdisciplinary patient-centered communication through the Family Meeting Model

Modernizing Palliative Care Delivery

The transition to a patient-centered care model must include thorough attention to the enormous role palliative care plays in cancer treatment. Palliative care is a critical component of cancer treatment due to its focus on improving both a patient’s functional status and overall quality of life, regardless of treatment outcomes. Recently, palliative care has gained attention as a specialty that is critical to improving patient quality of life while also improving efficiencies.

This is good news for the transition to patient-centered care, as palliative care, especially specialized palliative care, has been proven to reduce hospital stay lengths, lower provider expenditures, and free up resources previously devoted to critical care. On average, palliative care consultations result in savings of up to $1.3 million for a 300-bed community hospital and up to $2.5 million for the average academic medical center.² Palliative care also plays a role in improving patient survival rates, since the relief from pain and symptoms of cancer treatment actually helps patients complete their course of treatment.³ Furthermore, palliative care intervention can be a crucial window into exploring the value of treatment, enabling patients and families to make better decisions regarding their goals for care.

For this to happen, however, substantial changes must be made in the realm of palliative care delivery:

• Patients should be afforded increased access to specialist services so that high-quality palliative care can be available to more people.
• Palliative care delivery must move beyond inpatient and outpatient consultations. Patients, providers, and practitioners must be committed to moving palliative care forward to reach individuals earlier in their course of illness. This can be done by exploring open-access models that allow palliative and cancer treatments to be pursued simultaneously, as is currently allowed by CMS’ Care Choices Model.⁴
• Stronger patient outreach and education initiatives and improved physician-patient communication is critical to ensuring that patients and doctors are aware of all available options. Efforts must be undertaken to ensure practitioners are well-versed in primary palliative care so that some of the basic elements of palliative care can be delivered early in a patient’s treatment regimen.⁵
• Practitioners will need innovative approaches to delivering services to all patients, especially the seriously or terminally ill.

Such a cultural change in palliative care delivery can encourage patients and their families to become more engaged with practitioners, opening the door for better physician—patient relationships and easing the transition to a better patient-centered model of cancer care delivery.

Early Success in New Care Models

New York Oncology Hematology (NYOH), a leading provider of community-based cancer care services, has started implementing many of these approaches to palliative care delivery, with positive, measurable results. At a time when services are generally restricted to the inpatient and home settings, NYOH’s team has experimented with bringing services into the outpatient community setting, expanding access for patients while maintaining a high quality of care.

NYOH’s palliative care program is helping change the perception of palliative care: applying this integrated, coordinated approach to a mainstream care model that is available to all oncology patients has moved the perception away from that of a “crisis intervention” service that is typically assigned only to patients in a serious condition or near end-of-life.

Improving Navigation and Social Work Services

Physician practices are just 1 component of the oncology clinical setting. Equally important are the roles played by nonclinical interdisciplinary teams whose holistic management services impact a patient’s care plan, care experience, and overall well-being. Such an interdisciplinary team—which includes nonclinical staff, social workers, and nurse navigators—provides a critical link between the patient and the rest of the healthcare delivery process. This “navigation team” provides continuity of care over the course of treatment and ensures that important details are addressed as a patient transitions throughout the healthcare continuum. One way to enhance this coordination, and develop effective navigation teams, is to look at the strategies undertaken by IPUs and integrated care delivery systems. These networks have been successful in ensuring patients are cared for throughout the duration of their treatment, thanks to robust and effective interdisciplinary teams.¹

Any transition towards a patient-centered care model should ensure that special attention is paid to social workers, whose role in a patient’s treatment and recovery extends far beyond what a physician alone can provide. Social workers meet patients and families where they are at any given moment: at home, at the hospital, or in a community care setting. They are trained to deal with the psychological issues associated with chronic illness that many medical providers may not be equipped to observe or address. By listening to the patient and their family, social workers focus on bringing to light the mind, body, and spirit connection element of an illness, and they work on integrating it into the patient’s care plan. Any movement towards patient-centered care would benefit by ensuring that the interdisciplinary team remains an integral part of the care delivery model.

Improved Physician-Family Communication and the Family Meeting Model

The transition to patient-centered oncology care would be incomplete without open physician-patient communication and the full involvement of a patient’s family. Therefore, it is necessary to develop family support structures to facilitate communication among physicians, patients, and families.

Recent studies reveal significant room for improvement in the area of the physician-patient communication. Studies have found a high degree of discordance between the prognoses held by a physician and that physician’s oncology patient. Patients are often more optimistic about their prognoses than their doctors, and they are usually unaware that discrepancies exist between the two. A study of 236 oncology patients found that 68% of patient—oncologist survival prognosis ratings were discordant. About 89% of discordant patients did not know that their opinions differed from those of their oncologists. Nearly all believed that their prognoses were better than their doctors’ professional opinions.⁶

Meanwhile, oncologists and other specialists also face significant challenges with delivering bad news. Researchers in the conversation analysis field have consistently demonstrated that even when physicians are experienced in delivering bad prognoses, there is still an incentive to downplay or avoid giving the bad news. A study by Elizabeth Lamont and Nicholas Christakis found that physicians provided completely honest answers to patients only 37% of the time regarding their survival estimates, even when patients explicitly requested the information.⁷ Instead, doctors preferred to give inaccurate information (40% of the time, according to the study) or none at all (22.7% of the time). This trend held true even for patients with advanced or incurable cancer diagnoses. Clearly, there is a need for a better model of direct and honest physician-patient communication.

Fortunately, programs that emphasize patient-centered communication and family involvement have been shown to have a substantial impact on a patient’s well-being. The Values and Options in Cancer Care study, conducted by researchers at cancer clinics in western New York and northern California, found that individualized communication training programs for oncologists can result in clinically and statistically significant improvements in physician-patient communication.⁸ Participants who received the training scored better on the researchers’ composite measures of physician-patient communication than those who didn’t receive the training.

Furthermore, the Family Meeting model, which recognizes that cancer care frequently involves the patient’s entire family, can be an effective approach to developing sound patient-centered care. By recognizing that patients are almost never alone in facing their cancer treatment, practitioners—oncologists, nurses, and social workers alike—can orient their practice to be more patient-focused.

Paolo Gritti at the Second University of Naples has outlined several methods for implementing the Family Meeting model.⁹ It begins with the need to create a setting where open, frank discussions on patient health can take place. Oncology practitioners implementing the Family Meeting model should then be prepared to do the following:

• Share complete and accurate information about the patient’s diagnosis, condition, and prognosis.
• Discuss quality of care and establish an understanding of the patient’s/family’s views on cancer treatment and their goals for care.
• Inquire about how the family is coping or planning to cope with the disease and develop coping strategies.
• Recognize individuals’ emotions surrounding the patient’s diagnosis and account for differing feelings among family members.

At NYOH, practitioners are moving towards their own Family Meeting model to move cancer care from a reactive to a proactive process. Team members are coming together to share and develop a care plan that is driven by patient and family needs and goals, which reflects the whole patient experience. This is done via a forum where families can be educated and can discuss care options prior to an actual crisis. The NYOH Family Meeting model also encourages patients to be empowered to identify personal goals related to their treatment in a setting that welcomes open and honest discussion of all aspects of health, including topics previously considered taboo.

Conclusion

The transition to value-based, patient-centered care is not always simple or straightforward. However, with versatile interdisciplinary teams using effective tools and strategies that recognize the value of the patient and their support system in the treatment process, community-based cancer providers are measurably improving the care experience and outcomes for their patients. AUTHOR INFORMATION

Rufus Collea, MD, is medical director and physician lead for the Oncology Care Model project for New York Oncology Hematology.

Linda Pulver, RN, BA, is quality and clinical program lead for the Oncology Care Model project for New York Oncology Hematology.

Claire Ralli, LCSW, is a social worker at New York Oncology Hematology. Amanda Burgess, RN, OCN, is a nurse navigator at New York Oncology Hematology.

ADDRESS FOR CORRESPONDENCE

Linda Pulver, RN, BA

New York Oncology Hematology, PC

400 Patroon Creek Blvd

Albany, NY 12206

E-mail: linda.pulver@usoncology.com.REFERENCES

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2. Morrison RS, Penrod JD, Cassel JB, et al; Palliative Care Leadership Centers’ Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790. doi: 10.1001/archinte.168.16.1783.

3. Davis MP, Temel JS, Balboni T, Glare P. A review of the trials which examine early integration of outpatient and home palliative care for patients with serious illnesses. Ann Palliat Med. 2015;4(3):99-121. doi: 10.3978/j.issn.2224-5820.2015.04.04.

4. Medicare Care Choices Model. CMS website. https://innovation.cms.gov/initiatives/Medicare- Care-Choices/. Updated February 13, 2017. Accessed April 19, 2017.

5. Casarett D, Teno J. Why population health and palliative care need each other. JAMA. 2016;316(1):27-28. doi: 10.1001/jama.2016.5961.

6. Gramling R, Fiscella K, Xing G, et al. Determinants of patient-oncologist prognostic discordance in advanced cancer. JAMA Oncol. 2016; 2(11):1421-1426. doi: 10.1001/jamaoncol. 2016.1861.

7. Lamont EB, Christakis NA. Prognostic disclosure to patients with cancer near the end of life. Ann Intern Med. 2001;134(12):1096-1105.

8. Epstein RM, Duberstein PR, Fenton JJ, et al. Effect of a patient-centered communication intervention on oncologist-patient communication, quality of life, and health care utilization in advanced cancer: the VOICE randomized clinical trial. JAMA Oncol. 2017;3(1):92-100. doi: 10.1001/jamaoncol.2016.4373.

9. Gritti, P. The family meetings in oncology: some practical guidelines. Front Psychol. 2015;5:1552. doi: 10.3389/fpsyg.2014.01552. eCollection 2014.

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