ACCC Supports H.R. 5122, Legislation to Prohibit Medicare Part B Drug Demo

By Leah Ralph, Director of Health Policy, ACCC

Capitol BuildingThe Association of Community Cancer Centers (ACCC) thanks Representative Larry Bucshon (R-IN) for introducing H.R. 5122, legislation to prohibit further action on the Centers for Medicare & Medicaid Services (CMS) proposed rule for the Medicare Part B Drug Demo. ACCC urges prompt passage of H.R. 5122 in the U.S. House of Representatives.

ACCC remains strongly opposed to the Part B Drug Demo and is deeply concerned about the potential impact of this misguided proposal on both providers and the patients they serve.

Our membership, comprising approximately 2,000 practices and hospitals across the country, is committed to implementing value-based reforms and to continuing to work with CMS on meaningful payment reform—our members will be participating in the CMMI Oncology Care Model and investing in the infrastructure needed to comply with MACRA. However, CMS’ Part B Drug Model proposal is a nearsighted approach to Medicare reform.

ACCC supports H.R. 5122, and a full withdraw of the program, to provide the oncology community and CMS time to fully understand the impact of this policy and to work with CMS on meaningful reform.

For more on ACCC advocacy efforts on this issue, visit accc-cancer.org.

ACCC Asked: Congress Listened

By Leah Ralph, Director of Health Policy, ACCC

time for actionToday 242 members of Congress joined in a bipartisan letter to CMS Acting Administrator Andy Slavitt urging the agency to withdraw its proposed Medicare Part B Drug Payment Model.  The effort was spearheaded by House Ways and Means Committee Member and Budget Committee Chairman Tom Price, MD (R-GA), House Energy and Commerce Committee Member John Shimkus (R-IL), and House Ways and Means Committee Charles Boustany Jr., MD (R-LA).

You asked and Congress listened.  Last week, hundreds of ACCC members reached out to their legislators asking that they sign on to the Congressional letter to CMS.  ACCC thanks its membership from 2,000 cancer programs and practices across the country for speaking up and telling their legislators about the detrimental impact this proposed rule would have on their patients and providers.

But the question remains: Will CMS listen?

May 9 is the deadline for comments to CMS on this misguided proposal. ACCC will be submitting comments to the agency and urges its members to send comments as well.

Learn more about ACCC advocacy efforts on this issue here.

A Misguided Experiment?

By Leah Ralph, Director of Health Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoThe noise around drug costs seems to have gotten louder in recent months, with policymakers clamoring for controls on drug pricing, Congressional hearings calling on pharmaceutical executives to testify, and recommendations from the Medicare Payment Advisory Commission (MedPAC) focused on containing Medicare spending in the context of ever-increasing prescription drug costs.

In early March, the Centers for Medicare and Medicaid Services (CMS) issued a proposal to implement a national demonstration program that would target provider reimbursement and fundamentally change the way Medicare pays physicians and hospitals for Part B drugs. The scope of what CMS is proposing is sweeping. If finalized, it represents a significant departure from the methodology and philosophy underlying Medicare’s current reimbursement system, leading to bigger questions about the most appropriate—and effective—way to curb drug spending.

Mandatory Participation

 CMS has broad authority under the Center for Medicare & Medicaid Innovation (CMMI), created by the ACA, to test different models that would improve quality and lower costs in the Medicare program. However, the agency seems to be pushing the scope of its authority, breaking from past demonstration programs to propose a mandatory model in which all Part B providers–hospital outpatient departments, physician offices, and pharmacies–would be required to participate.

The proposed Part B Drug Payment Model would consist of two phases in which providers would be divided into four groups: three experimental groups and one control group over a five-year period. Phase I would be implemented as early as August 2016 and would mandate that approximately half of all Part B providers would have their reimbursement rates reduced to ASP+2.5% plus a flat fee of $16.80 per drug per day. Importantly, Congressionally-mandated sequestration will continue to apply to payments made under the model. As a result, under the proposal, the experimental group’s actual payment rate will be ASP+0.86% plus $16.53 per drug per day. The remaining half, the control group, would continue to be reimbursed for Part B drugs at ASP+6%. The goal, which policymakers have discussed for sometime, is to eliminate financial incentives for providers to prescribe more expensive drugs.

Ambitious Timeline

The agency’s ambitious timeline calls for Phase II to begin as early as January 2017. Phase II would further divide the control and test groups—creating a four-arm control trial—and overlay a requirement to use value-based pricing (VBP) reimbursement strategies and clinical decision support (CDS) tools to produce Medicare savings. One (unlucky) group of providers will be subject to both the reduced ASP rate and the requirement to utilize VBP tools. These tools might include:

  • Reference pricing: Medicare would set a standard payment for therapeutically similar products.
  • Indications-based pricing: Payment would vary for a drug based on its clinical effectiveness for different indications.
  • Voluntary-risk sharing agreements: CMS would enter into voluntary agreements with manufacturers to link health outcomes with payment.
  • Discounting or eliminating patient coinsurance to encourage beneficiary use of high-value drugs.

Unanswered Questions

Despite a preliminary list of potential tools, CMS failed to describe these VBP approaches in any meaningful detail, leaving many questions about how CMS will develop this methodology and how the agency will make determinations about high-value treatments.

Perhaps most unnerving, providers would be assigned to arms of the trial at random based on their geographic location in Primary Care Services Areas (PCSAs), which are clusters of ZIP codes that reflect primary care service delivery. Although CMS has structured Phase I to be budget-neutral for the Medicare program, among providers, there will be winners and losers: the program is designed to redistribute drug spending by increasing payments to provider specialties, such as primary care, that use relatively inexpensive drugs and decrease payments to hospitals and physician specialties, such as oncology and ophthalmology, that often use more costly drugs. Specifically, under the proposed model, the tipping point is $480–drugs that cost providers more than $480 per day on average would result in lower reimbursement, whereas products costing less than $480 per day would produce higher payments than what is reimbursed today.

The majority of drugs–7 of 10–that would make up the largest reduction in reimbursement are used to treat cancer. Moreover, many of these drugs do not have a lower cost alternative.1

ACCC Takes Action

 On both policy and process, ACCC remains deeply concerned. Rather than working with cancer care professionals to build the infrastructure needed to define quality and value in their cancer programs, CMS has responded to a call for reigning in drug costs with a myopic focus on reimbursement. Our members have partnered with CMS on meaningful payment reform – including the most recent Oncology Care Model – and will soon be dedicating extensive resources to navigating a new, and complex, reformed physician payment system under MACRA.

Oncologists are ready for change, but CMS’ proposal reaches too far, too fast, with seemingly little understanding of the devastating impact this approach will have on community cancer care and patient access.

Early on, ACCC joined with 60 oncology stakeholder groups in a letter to CMS asking the agency to withdraw its proposal. On March 17 ACCC, together with more than 300 state and national organizations, sent a letter to Congress asking policymakers not to move forward with the CMS Part B Drug Payment Model proposal. We recently partnered with the Hematology/Oncology Pharmacy Association (HOPA), the Oncology Nursing Society (ONS), and the Association of Oncology Social Work (AOSW) to caution Vice President Biden about how the proposal would impede the goals of the Administration’s cancer Moonshot initiative.

CMS will accept comments on the proposal until May 9, 2016. ACCC will be submitting a comment letter and urges members to express their concerns to the agency.

Access ACCC resources related to this issue and learn more about our advocacy efforts here.

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This post was updated on April 26, 2016.

Ready or Not. . . More ICD-10-CM Codes Coming October 2016!

By  Cindy Parman, CPC, CPC-H, RCC

Calendar pages and clockThe transition to ICD-10-CM diagnosis coding occurred October 1, 2015, but just like ICD-9-CM we will be seeing additions, deletions and revised codes each October until the U.S. moves to ICD-11-CM. Prior to the ICD-10-CM implementation, there was a code freeze and the code set remained in stasis. Beginning October 1, 2016, that changes. Although the final list of codes that will be effective on that date has not yet been published, there are potentially 1,943 new codes, 422 diagnosis codes with revised definitions, and 305 codes that will probably be deleted.

The public comment period for these planned updates closed on April 8, 2016. Both the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) will review all comments before issuing the final list of new, revised and deleted diagnosis codes in June 2016.

Proposed ICD-10-CM changes that will affect oncology include:

  • The addition of more codes to describe the anatomic sites of gastrointestinal stromal tumors
  • The revision of code definitions for Hodgkin lymphoma
  • Code additions for Castleman disease, mast cell activation syndrome and a specific code to report “Rising PSA following treatment for malignant neoplasm of prostate.”

In many instances an existing ICD-10-CM code will be deleted effective October 1, 2016, and replaced by multiple, more specific diagnosis codes. For example, the code for “Acute vascular disorders of intestine” will be deleted and replaced with 27 more specific diagnosis codes.

The ICD-10-CM Official Guidelines for Coding and Reporting, as well as code update information is located at: http://www.cdc.gov/nchs/icd/icd10cm.htm.

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Guest blogger Cindy Parman, CPC, CPC-H, RCC, authors the “Compliance” column for Oncology Issues, the journal of the Association of Community Cancer Centers.  She is a principal at Coding Strategies, Inc., in Powder Springs, Ga. Attend an ACCC Oncology Reimbursement Meeting to stay current with the latest trends and updates in oncology coding and reimbursement.

Patient Navigation: 20 Years in Review & My Lessons Learned

by Tricia Strusowski, MS, RN

Patient Navigation Compass for HealthcareIt is amazing how the world of patient navigation has changed over the last 20 years! Fate has aligned me with many wonderful opportunities, and over the years I’ve been honored to be an active participant both in the navigation role itself and in navigation program development. The journey has been a labor of love, a true passion, and extremely gratifying.

I was first introduced to the concept of navigation through my role in case management in the mid-1990s. Identifying the needs of the patients even before their cancer care commenced became a necessity to help transition the patients to the correct level of care. The goal was to provide the best services, decrease duplication of care, contain costs, and increase communication among the healthcare team. The patient and the family were active participants in their plan of care.

Toward the end of the decade, in 1998, my then-employer, Christiana Care Health System, Helen F. Graham Cancer Center, identified the need for “care coordination” for oncology patients and families (navigation was not yet a familiar term). We were one of the earlier adopters of “care coordination” or what we now call navigation. Our team consisted of disease-site-specific oncology nurses and social workers. We were under the “administrative microscope” to coordinate care across the continuum from cancer diagnosis through end of treatment or end-of-life care. After a bumpy start, we developed and then standardized our program.  We created pathways, guidelines, standing order sets, a patient journal, and patient tools, which are now called decision aids.  Learn more here.

Here are some navigation lessons learned over the years.

Lesson learned #1: Create tools and reports to reflect American College of Surgeons Commission on Cancer (CoC) national standards; identify metrics to demonstrate the success of your program. Define your reports and metrics for the staff so that information/data is collected in a consistent manner. 

As a new navigation program we initially made our patients and families too dependent on our services and as our volume increased, the caseloads became unmanageable. The staff became overwhelmed and we needed to address this immediately to provide the best service for our patients.

Lesson learned #2: Empower your patients with decision-aid tools/educational materials and provide health literacy training for staff. Monitor the caseloads and close cases when active treatment is completed. Hold morning meetings or huddles to share patient information with the healthcare team across the continuum.  Keeping your healthcare team updated increases productivity. 

In 2007 Christiana was an original member of the NCI Community Cancer Centers Program (NCCCP) initiative. I co-chaired the Quality of Care Subcommittee.   As a result of navigation discussions we created the Navigation Networking Committee and listserv; we held monthly conference calls to discuss our programs, best practices, document tools, and models of navigation. Our committee grew to more than 90 attendees. It was a fantastic learning and bonding experience; many of us are still close colleagues today. One resource developed through the NCCCP was a Navigation Assessment Tool for growing a program. Learn more.

Lesson learned # 3: Collaborate with your internal and external resources to identify best practices. Use the internal resources/experts in your healthcare system, i.e., pastoral care, finance, volunteer department, etc.  Partner with your external resources, such as the American Cancer Society (ACS), state Breast Cancer Coalition, Leukemia & Lymphoma Society, and Cancer Support Community. 

From 2008 to 2009 ACCC provided me with an exceptional opportunity to teach a two-day patient navigation workshop at six community cancer programs. I met with the teams and we discussed the goals, roles and responsibilities, documentation tools, job descriptions, guidelines, reports, and performance improvement initiatives. The programs were all very appreciative of the information because there really were not many resources available at the time. At the end of these training sessions ACCC held its first webinar on navigation.

Lesson learned # 4: Don’t reinvent the wheel. Today there are many resources available for navigation through ACCC, AONN+, ONS, AOSW, NCI, IOM, and  ASCO, just to name a few.  Network with your colleagues via listservs.

Navigation at times can be a “catch all” service; navigators may get bogged down with scheduling appointments, calling insurers, and data entry as well as other clerical duties.  Although some of these responsibilities are inevitable, it is important to identify support staff to assist with these tasks.

Lesson learned # 5: As a professional navigator it is essential that you function to the top of your license. You don’t want to turn into an expensive clerk.

Today, as I continue my role as independent consultant, I always tell my clients that patients and families always come first. If you take excellent care of the patients using national standards and best practices, the rest will fall into place.

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Guest blogger Tricia Strusowski, RN, MS, is a consultant with Oncology Solutions, LLC.

Patient-Centered Care—Empowering Patients, Engaging Providers

Jennie R. Crews, MD, MM, FACPEarlier this month, Jennie R. Crews, MD, FACP, began her tenure as ACCC President 2016-2017. Each ACCC President selects a theme issue. In this blog post, Dr. Crews discusses her President’s Theme: “Patient-Centered Care—Empowering Patients, Engaging Providers.”

By Jennie R. Crews, MD, FACP, ACCC President

As I begin my tenure as ACCC President, I am grateful to my predecessors for their leadership and for their contributions to the Association. They have left a wonderful and evolving legacy of presidential themes: from exploring the developing concept of the Oncology Medical Home; to providing the right care at the right time; to the importance of the multidisciplinary oncology team; to defining quality in oncology care; and, finally, revisiting the Oncology Medical Home theme as it relates to integrated healthcare delivery models. I hope to add to this evolving legacy with a presidential theme that focuses on patient-centered care:  Empowering Patients, Engaging Providers

Over the coming months, there will be many opportunities to explore this theme. While we all think we understand and provide patient-centered care, in our changing healthcare environment we are being challenged to examine how we define patient-centered care—both today and tomorrow. How do we continue to provide patient-centered care as we transition to new models of cancer care delivery? How will the changing role of the patient in consumer-driven healthcare influence what we think of as patient-centered care?

In our day-to-day work, so many of the challenges we face are based in our struggle to deliver patient-centered care:

  • The effort to ensure access to care−especially for patients in rural and underserved areas and for those with limited resources strained by the accelerating cost of cancer care.
  • The growth of personalized medicine with expanded use of genomic analysis and molecular testing and the consequent concerns of how to use this data and how to pay for it.
  • The imperative to meet accreditation requirements, such as survivorship care, and−most important−to ensure that this care is relevant and valuable to our patients.
  • The need to incorporate shared decision-making tools into busy programs to help patients clarify the value of outcomes, understand the financial impact of cancer treatment, and define their end-of-life wishes.
  • The enhanced use of patient-reported outcomes in cancer treatment and symptom management.
  • The implementation of new technologies to share data or provide telemedicine, including smart phone apps and patient portals that give patients new options in how they receive care, but which will require new forms of reimbursement.

To meet all of these challenges we must first involve and empower our patients, engaging all of the multidisciplinary providers on the oncology care team with these efforts. I look forward to working with the ACCC membership this year to explore creative and practical solutions to these challenges that we all face as we strive to keep the patient at the center of everything.

 

A Financial Advocate’s Six Steps to Cost Transparency

By Clara Lambert, Oncology Financial Navigator

Form-with-stethoscopeThe challenges of today’s healthcare environment mean that every patient with cancer can benefit from financial navigation. At some point during their treatment, most patients will have questions about their billing, and how it will affect their personal finances. Make sure your financial navigation process includes meeting with each new patient face-to-face. Whether this meeting is scheduled after their first appointment with the oncologist, or after their chemotherapy teaching and prior to beginning treatment, this face-to-face conversation is an opportunity for financial advocates to introduce themselves, explain their role, and help the patient feel more comfortable asking questions about costs of care early on rather than later when it may be too late to access assistance.

Here are six steps financial advocates can take toward cost transparency.

Step 1. Review All Insurance Benefits.

Before meeting for the first time with a new patient, financial advocates should review all of the patient’s insurance benefits.  This should be a comprehensive review conducted with the patient’s treatment plan in mind. Look at all hospital, medical, and pharmaceutical benefits, as the patient’s treatment could encompass some or all of these benefits.

Step 2. Work with Your Pharmacist & Chargemaster to Develop Price Estimates for More Common Treatments.

Developing price estimates for common treatments can help financial advocates streamline the financial navigation process.  At my facility, our pharmacist worked with our oncologists to develop the most common treatments for each diagnosis following NCCN Guidelines. The financial team is then able to work with that information to develop the price estimates.

Step 3. Personalize the Price Estimate to the Patient.

Taking the insurance review and the previously developed price estimates into account,  financial advocates can develop a personalized price estimate specific to each patient. You may want to develop a form to populate with this information so if the patient wants a copy of the information, it’s ready to go.

Step 4. Always Have a Plan in Mind.

Now that you have reviewed the patient’s benefits and prepared a personalized price estimate for the patient, you are almost ready for that first meeting.  Before meeting with a patient, you should prepare a plan outlining potential assistance.  Be sure your plan includes all of the qualification requirements for financial assistance and also verify that the fund is still open and accepting new applications. This advance work will help streamline the patient meeting, and allow you to start any applications immediately if the patient qualifies and is interested in pursuing financial assistance.

Step 5. Meet With The Patient.

From your very first meeting with the patient, it’s important to build a relationship. In this face-to-face meeting you will be getting to know the patient, as well as letting the patient know that you are there to help. You will need to make sure that your conversations are compassionate and understanding.

During the meeting, you will review the patient’s insurance benefits and the cost estimate for their plan of treatment.  There is often some patient education to help the patient understand his or her insurance benefits. As part of this meeting, complete a financial screening and begin the application process for the programs that the patient qualifies for.  The patient may be feeling overwhelmed with information, so preparing a checklist for the patient to identify any missing items will help them comply with supplying the information. It is best to submit an application for financial assistance when everything is complete, as many foundations will not look at an application until they have received all the required information.

Step 6. Follow Up & Track.

Many programs provide instant approval. For those programs that do not, you will need to set a follow-up reminder.  I typically follow up weekly.  If you receive a denial that you disagree with, know the appeal process, and begin immediately.  Once the application has been approved, make sure you notify the patient and billing personnel, and track the information to show the cost savings to your patient and your facility.

Guest blogger ACCC member Clara Lambert is an oncology financial navigator with Cancer Services at Munson Medical Center, and an active member of the ACCC Financial Advocacy Network (FAN).  Learn about upcoming ACCC FAN Case-Based Workshops here. Explore all of the ACCC FAN resources for oncology financial advocates here.

Caring for the Whole Patient—Two Cancer Programs; Two Approaches

One in an occasional blog series on topics from Oncology Issues, the journal of the Association of Community Cancer Centers.

By Susan van der Sommen, MHA, CMPE, FACHE, ACCC Editorial Committee Chair

Hands-creating-circle-of-supportThe pivotal 2013 Institute of Medicine* report, Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis, effectively outlines what those of us working in the cancer setting inherently know: More than 1.6 million patients are newly diagnosed with cancer annually; a number that is expected to rise to 2.3 million by 2030. The same report notes that by 2022, there will be 18 million cancer survivors in the U.S.

Cancer is indiscriminate. The newly-diagnosed are old, young, rich, and poor; fathers, mothers, daughters, sons, and siblings; they are single, married, bisexual, and gay; some are working, retired, on disability, or collecting social security. Two things these patients have in common are (1) they are people who are performing the activities of daily living—whatever  that may be—and  (2) cancer has changed their lives forever.

On a positive note, achievements in clinical science and treatment have led to earlier detection of many cancers, significantly increased life expectancy, and cured many of the disease. However, these same people may face other challenges often not detectable by the untrained eye: they are scared, anxious, depressed, and often suffering from considerable physical impairment that may dramatically impact their daily lives. As the 2008 IOM report Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs notes, these emotional, mental, and physical symptoms may be an exacerbation of issues the patient had prior to the cancer diagnosis.

The March/April edition of ACCC’s journal Oncology Issues includes feature articles that detail how two cancer programs have dramatically improved the lives of their patients (and patients’ caregivers) by instituting psychosocial distress screening and support programs. In their article, “Building a Navigation and Psychosocial Support Program from the Ground Up,” Lori McNulty, RN, and Faye Flemming, RN, BSN, OCN, describe how the Southside Regional Medical Center implemented a newly-developed patient navigation program as the foundation of their psychosocial support services. As with many cancer programs, Southside Regional Medical Center, though committed to furnishing these services, couldn’t justify the financial outlay needed to hire additional staff. By partnering with a local community organization, Southside Regional Medical Center was able to facilitate a patient-centered—and financially sustainable—approach to providing these vital services to their patients. Additionally, its  support program was established in such a way that the cancer program was able to meet many of the accreditation standards set forth by the Commission on Cancer.

The Norton Cancer Institute in Louisville, Kentucky, embedded a psycho-oncology program in its center to more effectively meet the needs of its patients’ psychosocial needs. Noting that psychological distress is common among cancer patients and often goes unrecognized, this ACCC member program developed the Norton Cancer Institute Behavioral Oncology Program (NCIBOP). As described in their article “Building Bridges, Breaking Down Barriers: An Embedded Psycho-Social Program Improves Patient-Centered Care,” NCIBOP is “a comprehensive, embedded psychiatric program with an emphasis on integrating high-quality psychiatric care to medically complex patients.” The program offers a multitude of group and individual therapy services and consultations in both the inpatient and outpatient setting. Staffed by three advanced practice RNs, a psychiatrist, a part-time social worker, a nurse, and two administrative staff, the team addresses the needs of approximately 800 patients per year. NCIBOP’s evidence-based, patient-centered approach has allowed many patients to experience a dramatic improvement in the quality of their lives.

Two cancer programs with two different approaches to meeting the cancer patients’ needs—these articles illustrate the complexity of oncology care delivery. At the same time, these divergent approaches also highlight the opportunity individual programs have to develop a programmatic structure designed to meet the needs of their unique patient population. The result? Patient-centric care models that meet the needs of the whole patient, just as the IOM report recommends.

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*Note: On March 15, 2016, the division of the National Academies of Sciences, Engineering, and Medicine (the Academies) that focuses on health and medicine was renamed the Health and Medicine Division (HMD) instead of using the name Institute of Medicine (IOM). For more information, visit www.nationalacademies.org.

Five Tips to Help Your Patients “Savor the Flavor” of Eating Well

In this follow-up National Nutrition Month post, guest blogger Colleen Gill, MS, RD, CSO, shares some tips for helping patients with cancer rediscover pleasure in eating. Ms. Gill is a clinical dietitian with the University of Colorado Cancer Center. She is also serves on the ACCC Board of Trustees.

Red appleBy Colleen Gill, MS, RD, CSO

National Nutrition Month is an opportunity for all of us to refresh our commitment to considering how we can help our patients with cancer rediscover joy in eating.   Even the 2016 National Nutrition Month theme, “Savor the Flavor of Eating Right,” reminds us of the obstacles faced by many patients, limiting their ability to experience the flavors and social experiences that food adds to our lives.

Five Strategies That Can Make a Difference

Here are some suggestions that can help patients eat well during and after treatment:

  1. Maintain traditions and social outings where food often plays an important role. During treatment, some patients choose to isolate themselves from such gatherings, adding to the sense of loss that accompanies diagnosis. Actually, most of us eat better in a social setting, enjoying the company around us. Accept the invitations that come your way and consider hosting your own events with a simplified potluck, or take out menu!
  2. It is OK to go slow. Eating slowly is not a bad thing, but rather a goal we all can adopt. It allows you to appreciate the flavors of the food, while giving your stomach time to signal when you are full. Don’t beat yourself up for being the last one done. If you are eating alone, or at home, consider pacing your meal/snack/drink with commercials on the television. Take a couple bites, or drink a couple ounces, with each commercial “reminder.”
  3. Go for flavor! When treatments affect taste buds, consider ethnic foods that have more spices and flavoring. As long as it doesn’t aggravate mouth sores or your stomach, there is no harm and a big upside.
  4. Make it easy and let others help! Coming up with ideas for meals and snacks can create stress for the whole family. Drafting a list of options that are “tolerable” for breakfast, lunch, dinner, and snacks saves everyone a lot of stress, guides shopping lists, and ensures enough variety so that no one burns out on eating the same thing over and over again. You can also add the extras that pack on calories, if you can’t eat a lot at one time. Softer, moist foods are often favorites. When people ask if they can help, provide them with a recipe. This saves you time and energy, and ensures that you will like what arrives.
  5. Don’t be afraid to eat out of fear of “feeding the cancer.” There is so much misinformation out there, and losing weight rapidly leaves you at risk of malnutrition, affecting your immune function and ability to heal, or even stay on treatment. Ask for a referral to a dietitian that works with cancer patients. He or she can give you individualized recommendations based on your cancer, treatments, weight and labs, as well as many other factors.

Some good resources are AICR’s H.E.A.L. Health Eating and Activity for Living Well: A Cancer Nutrition Guide and the Academy of Nutrition and Dietetics Oncology Dietetic Practice Group FAQs page here.

 

Improving Patient Outcomes with Nutrition Services—What a Dietitian Can Do for Your Cancer Center

March is National Nutrition Month. ACCCBuzz has invited guest blogger Colleen Gill, MS, RD, CSO, to share her perspectives on the value dietitian services can bring to cancer care services. Ms. Gill is a clinical dietitian with the University of Colorado Cancer Center. She is also serves on the ACCC Board of Trustees.

Red appleBy Colleen Gill, MS, RD, CSO

Although 90 percent of cancer treatment occurs in clinics, dietitian services have not been universally available in the outpatient setting. While for inpatients some level of coverage for dietitian services exists, the focus is rarely on issues patients encounter after discharge from the hospital and while undergoing anticancer treatment.

In 2012, the American College of Surgeons Commission on Cancer (ACOS CoC) added a standard to address nutrition (Eligibility Requirement 12), stating: “a policy or procedure is in place to access nutrition services either on site or by referral.” This is a step in the right direction; however, the process is left up to each center, which can result in token efforts without administrative endorsement of supportive oncology services.

Over the past five years, staffing surveys have found that many more cancer centers have added nutrition services and, more significantly, have noted improved patient and staff satisfaction that has led to hiring of additional dietitians. A study is currently being funded by the Institutes of Medicine (IOM) to identify optimal staffing based on patient need rather than current practice. The IOM Planning Committee on Assessing Nutrition Care in Outpatient Oncology is hosting a one-day workshop on Monday, March 14, which will be open for the public to watch as a webcast. Event details and registration information is available here.

The Role of Nutrition Support for Patients with Cancer

Discussion of the role of nutrition support for cancer patients has a long history. In 1980, DeWys and colleagues published ECOG data showing that weight loss was associated with poor outcomes in cancer patients. In 1998, Andreyev and colleagues identified increased toxicities and shorter treatment duration as outcomes of weight loss, and noted this resolved with stabilization of weight. Since then research has found that nutrition support helps manage symptoms, improving intake and thus stabilizing weight, nutrition and hydration status, normalizing bowel patterns. This keeps patients on treatment pathways without interruptions related to failure to thrive and hospital admissions for dehydration. Across the continuum of cancer care, nutrition support is associated with improved quality of life (QOL), better maintenance of muscle mass and functional status, and improved tolerance of treatment with better outcomes. Eating also allows patients to sustain social connections, while minimizing conflicts around eating that can arise from family concerns and pressures.

Five Basic Steps for Starting a Nutrition Program

For cancer programs interested in starting a nutrition program, five basic steps include:

  1. Screening.
  • Criteria are now well defined* and include assessment of any losses in muscle mass and evaluation of the rate of weight loss. Interestingly, obesity is actually a predictor of higher rates of malnutrition, though with delayed recognition.

*Consensus papers on the assessment of malnutrition were published in ASPEN and the Journal of Nutrition and Dietetics in 2012. In 2013, Jensen, Compher, Sullivan and Mullin followed with a summary of strategies to implement a multidisciplinary team approach to identifying patients at risk.

  • Screening should be done at least monthly, as therapies can and do change over time and create new barriers to eating. Identifying and addressing changes and new symptoms proactively will lessen their impact and the likelihood the patient will become malnourished.
  • In a recent review of screening tools (Skipper A, et al., 2012), the Malnutrition Screening Tool (MST), which uses unintentional weight loss and reduced appetite, was found to have the greatest validity and reliability. In some cancer centers, screening is implemented with a simple question that includes these factors; the screening question is added to the list that the medical assistant reviews with the patient at each visit. For example, asking patients: “Are you experiencing any difficulties with eating that limit your ability to maintain your weight?”
  1. Initiation of interventions in patients at nutrition risk, by diagnosis, weight/muscle loss.
  1. Staff and patient education activities.
  • Identifying or creating materials needed to address symptom management issues
  • Educating staff where appropriate, i.e., enzyme dosing for malabsorption, bowel regimens, TPN monitoring/support
  • Support group lectures
  • Supervising nutrition rotations for local internship programs, medical school electives
  1. Involvement in outreach activities that increase the visibility of nutrition support services.
  • For example, through outreach activities with Living Beyond Breast Cancer, Lymphoma and Leukemia Society, or similar support groups
  • Community lectures on complementary/integrative nutrition topics. Sample topics might include:  Limiting the adoption of extremely restrictive diets that are not evidenced based; helping patients integrate nutrition without creating a new stress in their lives; and addressing issues such as supplementation, weight management, and exercise.
  • Cooking classes
  • PR requests from local media
  1. Hiring carefully. Find candidates with a passion for oncology and a desire to make a difference. A registered dietitian nutritionist (RD/RDN) with 2,000 hours of oncology experience can take a certification exam to become a board certified specialist in oncology (CSO).

Here are some resources to help get you started:

American Institute on Cancer Research: www.aicr.org

  • The plate model as a visual guide for a healthy diet
  • Continuous Update Reports on specific cancers and diet
  • Symptom management materials:  HEAL Well: A Cancer Nutrition Guide

Association of Community Cancer Centers: Cancer Nutrition Provider Resources

The Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics;      FAQs www.oncologynutrition.org/erfc/healthy-nutrition-now/foods/  Materials to address questions on juicing, sugar and cancer, soy, etc.

ACS Nutrition and Physical Activity Guidelines for Cancer Survivors, 2012.