Three Ways to Support Your Cancer Registrars

By Linda Corrigan, MHE, RHIT, CTR

Check boxCommission on Cancer (CoC) Cancer Program Standards 2016 are designed to ensure a comprehensive approach to the care and treatment of patients. Cancer programs seeking CoC accreditation must demonstrate that they’ve met or exceeded these standards—many of which require data tracking. Your cancer registrar can assist your clinicians in designing the best “tracking tool” for your program. For many programs, the best tool will be your cancer registry software. Cancer registrars well-versed in high quality data collection are key to the success of a cancer program. In turn, there are three critical ways your program can support its cancer registrars:

  • Make sure your cancer registrars are up-to-date by supporting training and continuing education opportunities. Change is a constant in the world of oncology. Treatments are advancing, CoC standards are added and/or revised, and state cancer registry data-collection guidelines are updated annually. A prime example of this constant change is the American Joint Committee on Cancer’s (AJCC) soon-to-be-released Cancer Staging Manual. The new 8th edition, scheduled for publication in October 2016, will revise how cancer is staged.
  • Encourage your cancer registrars to get involved in state and national organizations and provide funds for them to attend meetings and conferences. The key to helping your cancer registrar stay current is networking and continuing education. Some registrars have as many as three separate organizations and/or federal agencies that “set” the standards for exactly how and what data are collected from a facility’s cancer program. Cancer registrars who attend national conferences and state meetings or who are encouraged to volunteer for national and state-level organizations develop a network of colleagues from across the country that can be tapped as a resource when your program has questions.
  • Staff your cancer registry appropriately. The best way to support and retain your cancer registrar and to ensure high-quality data collection is to make sure you have the staffing bandwidth for the number of cancer cases your facility manages each year. Review NCRA’s Workload and Staffing Study: Guidelines for Hospital Cancer Registry Programs to help assess your staffing needs.

The National Cancer Registrars Association (NCRA) and the Association of Community Cancer Centers (ACCC) are two national associations that can help cancer programs support their cancer registrars. NCRA’s Annual Educational Conference provides a thorough and cost-effective way for cancer registrars to stay informed and to network. Attendees learn about updates to treatments and staging, CoC standards, clinical trials, and national trends. The 2017 conference, scheduled for April 5-8, in Washington, D.C., will focus on the AJCC’s 8th edition of the Cancer Staging Manual. Look for conference updates on the NCRA website here.  NCRA’s Center for Cancer Registry Education is a learning management system designed to provide easy access to high-quality educational programming. The website offers a variety of online products to help registrars tailor training and manage the continuing education credits needed to maintain their Certified Tumor Registrar (CTR) credential.

ACCC is also a great resource for cancer registrars. ACCCExchange, the association’s online member discussion forum, connects registrars with peer-to-peer solutions, strategies, and resources for how to best meet CoC standards. ACCC’s journal Oncology Issues provides in-depth articles on programmatic innovations implemented by ACCC member programs, coding updates, and advocacy issues—and can be a valuable resource for registrars to better understand advancements in cancer treatment and care. Coming in October, the ACCC 33rd National Oncology Conference in St. Louis will focus on practical “how to’s” for cancer programs and practices, with peer-to-peer learning on process improvement strategies, putting data to work to improve care, and more. Learn more here.

Contributing blogger ACCC member Linda Corrigan, MHE, RHIT, CTR, is president, National Cancer Registrars Association.

Building a Palliative Care Program from the Inside Out

By Michelle Abramowski, MSN, CRNP, and Patsy Astarita, LCSW-C, OSW-C

Palliative care has become an essential part of oncology care, particularly in patients with stage IV cancers, multiple co-morbidities, or advancing cancer despite treatment. The literature supports the value of collaborative oncology and palliative care services.1,2 While many cancer programs have developed outpatient palliative care clinics to meet this need, others may be challenged to offer these services on an outpatients basis.

At the Kaufman Cancer Center  we used existing resources to create a multidisciplinary outpatient palliative care program that addresses the care management and goals of our patients with advanced cancer. In October, this initiative will be recognized with a 2016 ACCC Innovator Award at the ACCC 33rd National Oncology Conference in St. Louis.


In a conference session on Friday, October 21, we will be sharing the “how to’s” of building a palliative care program by starting where you. Here’s a sneak peek at how we did it.

First Things First

Our first step was to identify existing challenges and strengths.

Challenges  

  • Inadequate communication between treatment teams
  • Lack of education related to palliative care
  • No budget
  • Documentation challenges and data management
  • Existing hospital palliative team focused on ICU
  • Patient navigation emphasis on newly diagnosed patients instead of palliative care
  • Reactive versus proactive use of resources.

 Strengths

  • Existing leaders and clinicians with a passion for palliative care
  • Creating a culture of sensitivity change
  • Existing inpatient palliative care program focused on improving quality outcomes and providing cost-effective care
  • Transitioning from fee-for-service to value-based care payer model.

Building Begins

In the summer of 2014, we formed a workgroup that included key members of our clinical team. We reviewed literature, evaluated existing models, identified national metrics, and selected specific outcome measures to track our progress.

In October 2014, we launched a weekly palliative care conference. This multidisciplinary conference includes oncologists, nurse practitioners, nurses, social workers, dietitians, and pharmacists. Every clinical area of the cancer treatment team is included and represented. Our team developed a decision-making tool to help identify patients in need of palliative care. The initial focus was patients with evidence of non-curative disease and/or an ECOG performance status of 2 or greater. Additionally, we incorporated use of Glare’s validated 5-item palliative care questionnaire.3

We identified key clinical team members willing to become palliative care experts within their discipline through personal education and the development of palliative care skills. This group of specialists meets bi-monthly to gain and share knowledge, develop new palliative care skills, and to monitor overall progress of our on-going effort.

Where We Are Now & What Lies Ahead

 As we near the two-year mark on this effort, we are seeing:

  • Fewer Emergency Department visits
  • Reduced ICU admissions
  • Earlier admission to hospice
  • Reduction in end-of-life chemotherapy
  • Earlier and more frequent “goals of care” meetings
  • Improved communication between patient, families, and treatment team.

And we’ve identified the following goals to continue moving our palliative care services forward:

  • Ongoing education and development of our palliative experts
  • Incorporation into multidisciplinary clinics
  • Updating patient educational materials
  • Improving community partnership
  • Continuing to track outcomes and identify new measures of success
  • Increasing visibility and awareness of our palliative care resources.

Four Lessons Learned

Our experiences building our palliative care services have taught us:

  • How to use valuable existing resources
  • Early palliative care intervention improves outcomes
  • Invite everyone to participate—multidisciplinary expertise is vital
  • Secure support from leadership early in the process.

How About You?

Our patient-centered model of palliative care is a continuous process that focuses on our patients’ values, beliefs, and wishes for end-of-life care. Discover what talent already exists in your cancer program that can help reduce patient suffering, improve quality of care, and make best use of your resources. Can you create a program from the inside out?

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References

1Temel J, Greer J, et al. Early palliative care for patients with metastatic non-small cell lung cancer. N Engl J Med. 2010;363:733-742.http://www.nejm.org/doi/pdf/10.1056/NEJMoa1000678
2May P, et al.  Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: Earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33, 1-8.
3Glare, et al. Palliative care in the outpatient oncology setting: evaluation of a practical set of referral criteria. J Oncol Pract. 2011;366-370.  www.jop.ascopubs.org/content/7/6/366.full


Michelle Abramowski, MSN, CRNP, is nurse practitioner, and Patsy Astarita, LCSW-C, OSW-C, is manager, Supportive Care & Community Services, UMD Upper Chesapeake Health, Kaufman Cancer Center.

 

Palliative Care: Patient-Centered Support

By Sandy Balentine, MSN, RN, OCN, MBA

HC provider cupping patients hand (for web)The understanding that palliative care is not hospice care has been, and continues to be, a challenge for both patients and providers to grasp. Palliative care is “. . . specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.”1  Palliative care is appropriate at any age and at any stage of a serious illness. It is offered alongside—not instead of—curative  care.

Hospice is a philosophy of care for people who are near end of life and are no longer seeking curative treatment.

Palliative Care—Part of Team-Based Care

The role of palliative care is to treat pain and other symptoms, and help patients realistically review the goals of their care. Clinicians trained in the subspecialty of palliative care work together with the patient’s disease-directed care team, helping to better meet the patient’s needs with a team-based approach. The team includes nurse practitioners, physicians, social workers, dietitians, chaplains, pharmacists, registered nurses, and others. The team helps patients gain control of their illness by exploring their goals of care, better understand their treatment options, and avoid unwanted care.  A partnership develops that includes the palliative care team, the patient, and the patient’s family. Patients are relieved to have help with understanding what to expect and how to handle it, and difficult decisions can be made with more information and insight.  Palliative care can help patients and their families cope with the challenges of living with a serious illness. Family members receive support, and as a result feel they can, in turn, better support their loved one.

A Focus on Quality of Life

A pivotal study of patients with metastatic NSCLC by Jennifer Temel and colleagues demonstrated that early palliative care showed significant improvements in quality of life and mood, as patients received less aggressive treatment at end of life but experienced longer survival.

The Institute of Medicine’s (IOM’s) 2013 report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, cites the need for improved access to palliative care for patients with cancer, noting that:

“Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence.”

At Valley Hospital, we recognized the difference that palliative care can make in the quality of life for our cancer patients.  We started with an inpatient palliative care program and today also offer palliative care in the outpatient setting or for homebound patients at home in the privacy of their residence. This service is an extra layer of support for an improved quality of life for our patients.

Growing Services to Meet Patients’ Needs

By the end of 2014, our inpatient palliative care service was extraordinarily busy, and the team knew that this service needed to be available to patients before they were admitted to the hospital in a crisis situation. With improved symptom management, hopefully some of these patients could avoid being admitted to the hospital. So we began the process of developing a palliative care service for our outpatients. Our first step was to put together a multidisciplinary weekly meeting that included a psychiatrist, pain management physician, palliative care nurse practitioner, chaplain, pharmacist, social workers, registered nurses and others. This team would review cases and give input and recommendations, combining the joint knowledge of the group. Patients were identified through the physician practice providers, Infusion Center or Radiation Oncology staff, or by self-referral.

As we began to develop the outpatient program, it quickly became obvious that there was a population whose needs we were not meeting. These patients were homebound or had an extremely difficult time getting in to the office.  Still, these patients needed the support that palliative care could provide. To meet this need, our home care agency has now started to integrate palliative care support to our homebound/home care patients as well.

Improving Access for All

Although great strides have been made in palliative care in the last few years, access to these services remains uneven. Palliative care is not available in many smaller hospitals or in rural areas. According to a 2015 report from the Center to Advance Palliative Care (CAPC), Alabama is one of the states with the lowest access, with less than one third of hospitals offering palliative care.  Reasons for this low coverage include a lack of knowledge about palliative care among healthcare providers, socioeconomic factors, geographic factors, transportation issues, and other factors. CAPC is a national organization dedicated to increasing access to quality palliative care for people facing serious illness. CAPC has helped the advancement of palliative care services by providing tools, training, and technical assistance to clinicians as a catalyst to change the conversation around palliative care.  CAPC’s vision is simple: to have palliative care available everywhere.

To ensure that health professionals understand the quality of life issues that exist for their patients, students in medicine, nursing, social work, psychology, and pastoral care, all need to have a robust educational program to help them understand what palliative care encompasses and how it can help patients. This training needs to include early lessons on discussing end-of-life decisions, how to handle anger and sadness from families, and how to respond personally to the loss of a patient. Only then will we be able to approach CAPC’s vision of palliative care available to every patient.

Stay tuned for an upcoming blog from 2016 ACCC Innovator Award winner University of Maryland Upper Chesapeake Health, Kaufman Cancer Center on how to build a palliative care program “From the Inside Out.”

_________________________

Reference
1Center to Advance Palliative Care.  About Palliative Care. Available at www.capc.org/about/palliative-care.


ACCCBuzz contributing blogger Sandy Balentine, MSN, RN, OCN, MBA, is the Director of Clinical Oncology at ACCC Member Program, The Valley Hospital.

HPV Vaccination: Engaging Community Partners for Success

By Amy Montgomery

ACCCBuzz guest blogger Amy Montgomery is Senior Administrator of Operations at The Outer Banks Hospital in Nags Head, North Carolina.

Innovator Seal16singularThe recent American Cancer Society (ACS) endorsement of the U.S. government’s HPV vaccination recommendation signals the start of a new and refreshing conversation.  The updated (ACS) guideline supports the Centers for Disease Control and Preventions (CDC) Advisory Committee on Immunization Practices (ACIP) recommendation to vaccinate both males and females at ages 11 to 12 to protect against HPV.

We have known for years that the vaccine was designed to prevent the human papilloma virus (HPV), which is associated with the vast majority of cervical, vaginal, vulvar, anal, penile, and oropharyngeal cancers.  What we have done, to some degree, is avoid the topic all together.  Until recently, the HPV vaccine was a conversation about whether or not giving the vaccine to a child would lead to early sexual behavior.  Simply put, early sexual behavior is a scary topic for most parents of preteen children.  So, the conversation stopped there.  In the doctor’s office, at the bus stop, at book club – all the places where the topic might come up – it most likely turned toward early sexual behavior, with the cancer prevention benefits of the vaccine left unexplored.

Not any longer.  With the guidance of the CDC and the leadership of the American Cancer Society, the common ground upon which most of us can agree is that HPV vaccination is a powerful tool in our cancer prevention kit.  This is a message that resonates with parents.  The conversation starts like this, “If you could prevent your child from developing a certain type of cancer as an adult later in life, would you do it?”  As a parent, you had me at “prevent my child from getting cancer.”  The door is now open to how, when, and where can I have my child vaccinated.

The Outer Banks Hospital Cancer Committee began using this new conversation when we undertook an initiative to increase the HPV vaccination rate among students enrolled in our local public schools.  This approach helped us gain the support of key community partners including our hospital president, the school system superintendent, and local health department director.  This approach also resonated with parents, demonstrated by the increase in our vaccination rates from 6 percent to 16 percent among 8th grade students in just one year.

Some strategies we used to start this new conversation included:

1)      a cover story in our hospital’s community newsletter

2)      a letter to local physicians from our Cancer Committee physician liaison

3)      flyers sent home in report cards

4)      presentations at back-to-school parent meetings

We also found modest success with older students.  Our efforts increased the vaccination rate from 20 percent to 23 percent among rising high school seniors.  What we learned is that different strategies are needed to encourage catch-up vaccines for this age group.  That is something our team will be exploring as we continue this cancer prevention work.

The Outer Banks Hospital is honored to be a recognized with a 2016 ACCC Innovator Award for our initiative on HPV Vaccination: Engaging Community Partners for Success. At the upcoming  ACCC 33rd National Oncology Conference October 19-21, in St. Louis, Missouri,  we will be describing  how we worked with our community partners to encourage conversation about HPV vaccination and cancer prevention.  Watch our short Innovator Award video to learn more about our initiative.

Join us and all of the 2016 ACCC Innovator Award winners in St. Louis, and hear inspirational, real-world approaches to complex challenges in delivering quality care to serve our communities. View the conference agenda and register today!


Patient Navigation: Reducing Delays in Care

By Tricia Strusowski, MS, RN

Solutions on corkboard-smallOur last navigation blog discussed how process mapping by disease site can help in managing transitions across the continuum of care.  Process mapping helps the cancer care team identify when to initiate patient navigation and support services as well as to identify goals, barriers, and gaps in care.

Removing barriers and gaps in care is a major goal for any navigation program. Many patients have shared with me that delays in care are the most stressful part of their treatment journey; they call it the “waiting game.” While they are waiting, their imagination can get the best of them. They are not only imaging “the worst” but also questioning “who is coordinating my care?” And if these delays occur time after time across the care continuum—they can have significant implications for the patient’s treatment journey. Is this acceptable?  Absolutely not.

So, How Do We Fix This?  

A great solution to eliminating delays is to create a continuum of care spreadsheet in your electronic medical record (EMR).  Use your process map to help identify the different departments and offices with visits that must be coordinated to avoid delays across the continuum.

The first step in creating your continuum of care spreadsheet is to identify the specific appointments and office visits in the correct order.  Each cancer disease site will look a bit different based on the specific needs of the patient.  For example, let’s consider what this might look like for a head and neck cancer patient. We all know that the patient must have dental clearance prior to any chemotherapy or radiation therapy treatment, but what is an acceptable time frame for this step? One week? Two weeks?  To avoid delays in the patient’s treatment journey, an early appointment for dental clearance is a must and should be completed as soon as possible.

Below is an example of the fields for an overly simplified basic continuum of care spreadsheet.  If an EMR is not available, you can use an Excel spreadsheet to create your continuum of care.  You can also add the initiation of navigation, support services, and survivorship care plan into the care continuum. 

  • Diagnostic work up, imaging, tests, and dates
  • Surgical consult, visit and date
  • Surgical biopsy and date
  • Pathology report results and date
  • Surgery and date
  • Medical Oncology consult, visit and date
  • First chemotherapy treatment and date
  • Radiation Oncology consult visits and date
  • CT simulation and date
  • First Radiation Oncology treatment and date.

Next, your multidisciplinary team needs to review the actual or “real” time period for the delays.  An audit will help you identify the true time lapse between each episode of care.

With these steps completed, you’re ready to initiate a performance improvement (PI) project to decrease delays. The team needs to discuss and create new acceptable time frames between the visits. Identify where the delay is occurring: Registration? Insurance verification? Scheduling?  Look for opportunities to meet with the different departments and offices to brainstorm how these delays can be reduced.  Many times you may also identify duplication of services. Eliminating these redundancies will help with staff productivity.

Sustainability is Key

Once you’ve reduced the delays, you will still need to monitor the new process to ensure that it is continuing to be effective—monitor monthly at first and then move to quarterly or bi-annual monitoring as needed. If the new process is not working, revisit the opportunities for improvement.  Finally, remember that the main goal of all of our programs is to work as efficiently as possible while keeping the patient at the center of all we do.

An efficient and timely patient-centered flow will enhance your patient experience!


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

Tap Into the Expertise of Your Cancer Registrar

By Linda Corrigan, MHE, RHIT, CTR

ThinkstockPhotos-507273299Hospitals understand their cancer registry data are sent to state and federal agencies to document incidence rates and to identify cancer clusters. But many may not be realizing the full potential of their cancer registry database, a goldmine full of information that can help your facility. Hospital-specific data provide a wealth of information that can assist with financial and strategic planning, assessing timeliness of treatment, understanding survival rates, conducting community needs assessments, and implementing targeted marketing initiatives.

As the custodians of your data, cancer registrars know it better than anyone and can see trends as they happen. Make sure to include your cancer registrar in meetings and ask for updates. Tap into your cancer registrar’s expertise and put your data to work. Your cancer registrar can:

  • Help your program justify additional staff. For example, by monitoring case volume by site, year, and insurance coverage, your cancer registrar can supply data to make the case for adding physicians to your cancer program.
  • Run reports to identify patterns (or specifics) about who is seen in your cancer program by identifying referring physicians or hospitals. These data can help track trends in patient retention as well as outmigration.
  • Assist with quality improvement/process improvement initiatives. For instance, time to treatment is a frequent target for cancer program improvement efforts. Your cancer registrar can do a deep data dive into your patient population and uncover the exact profile of those patients experiencing the greatest delays.
  • Collect specific data to generate custom reports through user-defined fields in the database. What data do you want to collect? Many registrars have already started reviewing patients seen in the beginning of 2016, so now is the time to talk with your cancer registrar about any additional data you may need for future reports.
  • Compare your data (demographics and disease-site specific data) to that housed in several other national databases.
  • Support your Cancer Committee with data that identifies your patient population and specific health disparities in your service area as the triennial Community Needs Assessment is being completed.

These are just some of the many ways the expertise of your cancer registrar can support your cancer program. An upcoming ACCCBuzz blog post will explore the evolving role of cancer registrars and how your oncology program can support registrars as an integral member of the cancer care team.


ACCC Member Linda Corrigan, MHE, RHIT, CTR, is currently serving as President of the National Cancer Registrars Association.  Learn about the NCRA Annual Education Conference, April 5-7, 2017, here.  Explore NCRA’s Center for Cancer Registry Education here.  The January/February 2016 Oncology Issues features, “Unlock the Potential of the Cancer Registrar,” an article co-authored by Ms. Corrigan that describes how cancer registrars can support lung screening programs within community cancer centers.

The Power of Sharing Your Story

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

Talking heads At the upcoming ACCC 33rd National Oncology Conference October 19-21, in St. Louis, Missouri, the 2016 ACCC Innovator Award winners will be showcasing their pioneering efforts aimed at improving the provision of care to cancer patients with initiatives that can be replicated in other community cancer programs.

Spreading the Word

In addition to speaking at the National Oncology Conference, every ACCC Innovator Award winner has the unique opportunity to write a feature article for Oncology Issues, ACCC’s bi-monthly journal.  The just-released July/August 2016 issue presents in-depth, “how we did it” articles from several of the 2015 Innovator Award winning programs. But opportunities for ACCC members to share their cancer program’s initiatives and successes are not limited to Innovator Award winners. Oncology Issues features insightful articles from ACCC member programs throughout the country – large and small. And every issue includes a “Spotlight” article profiling an ACCC Cancer Program member.

For instance, in the January/February 2016 issue, authors from two ACCC Cancer Program member institutions wrote about how to “Unlock the Potential of the Cancer Registrar,” describing the integral role their cancer registrars are playing in their organizations’ lung screening programs. And the May/June 2016 issue featured an article from ACCC Cancer Program Member The Valley Hospital’s Blumenthal Cancer Center on its Oncology Nursing Fellowship Program. In feature articles such as these, ACCC members share their real-world strategies for overcoming challenges and improving oncology care delivery, enriching the oncology community as a whole.

What better way to feature your cancer program’s success than through an article or profile published in a journal with national coverage? Many of our colleagues have used the opportunity to garner local media coverage in their respective markets; others have showcased their work among their peer group – which sometimes includes much larger centers.

In a recent ACCC Communications Survey, ACCC members were polled on the association’s journal, Oncology Issues:

  • 90% said that Oncology Issues is the “primary benefit of ACCC membership.”
  • 98% said that Oncology Issues “contains practical information, insights, ideas, and tools.”
  • 92% said that Oncology Issues “contains information that I do not find in other sources.”
  • 88% said that Oncology Issues “helps my cancer program stay ahead of the competition.”
  • 88% said that Oncology Issues is “must reading for me to stay ahead in my profession.”

What makes the Oncology Issues so successful? Input from ACCC cancer program members like you! To help spread the word to ACCC members about opportunities to contribute to the journal and how Oncology Issues’ content can be leveraged to benefit your program, this year’s National Oncology Conference will feature a new agenda item – “Oncology Issues Live!” hosted by members of ACCC’s Editorial Committee. Interesting in learning more about contributing or having your program featured in Oncology Issues? Want to be part of the Editorial Committee? Come to “Oncology Issues Live!” at the ACCC 33rd National Oncology Conference, October 19-21 in St. Louis, and connect with us.

 

MACRA Update—Will CMS Delay the Start Date?

By Brittney Fairman, Policy Analyst, ACCC

Calendar pages and clockLast week Andy Slavitt, Acting Administrator for the Centers for Medicare & Medicaid Services (CMS), told the Senate Finance Committee that the agency was considering “alternative start dates,” for Medicare Access and CHIP Reauthorization Act (MACRA) after receiving more than 3,000 comments on its proposed rule implementing the Quality Payment Program. The final rule is expected in November, leaving only a few months before the proposed reporting start date of January 1, 2017. Slavitt also said the agency is taking a close look at how the proposed rule would impact rural and small providers, particularly the low volume threshold that would exempt small practices from certain reporting requirements.

In our June 27 comment letter on the MACRA proposed rule, ACCC urged CMS to:

  • Delay implementation for six months to one year, to give physicians the time needed to build infrastructure and implement the Quality Payment Program effectively
  • Ensure that the agency provides adequate accommodations and protections for small group practices and solo practitioners
  • Modify the “resource use” methodology to ensure that eligible clinicians are held responsible only for the costs they can control
  • Include all Oncology Care Model (OCM) quality measures in MIPS
  • Refine the APM requirements to offer a meaningful alternative to MIPS and adopt policies to promote the availability of a wide variety of APMs and Physician-Focused Payment Models (PFPMs).

With this proposed rule, CMS aims to transition Medicare to a new physician payment program focused on quality, value, and accountability over volume. The MACRA legislation enacted by Congress outlines essentially two separate payment pathways for physicians under Medicare: The Merit-Based Incentive Payment System (MIPS), and the Alternative Payment Models (APMs). Both pathways are intended to drive the development of value-based payment. ACCC supports payment reform efforts; however, it is critical that CMS construct these pathways so that they are realistic, achievable avenues to Part B reimbursement.

ACCC will continue to keep members informed as MACRA implementation unfolds. For a deeper dive on new requirements under the Quality Payment Program, ACCC members can access the recent ACCC webinar, “MACRA CMS Proposed Rule: What You Need to Know” on demand (login required). The American Medical Association (AMA) has created a MACRA Checklist that outlines steps providers can take now to prepare, as we await the final rule.

Helping Patients Cope with “Chemo Brain”

By Sandy Balentine, MSN, RN

Gears in Bubble HeadHave you ever had your chemotherapy patients say that they “can’t remember anything,” they “just can’t concentrate,” or they “feel foggy”? The term “chemo brain” is often used to describe these phenomena. So, what is “chemo brain,” and is it real?

Chemo brain has been described as cognitive or thought problems that occur during and after cancer treatments—with either chemotherapy or whole brain radiation. Patients report having trouble concentrating or focusing, problems with word or name recall, and slowed thinking that results in a longer time to complete tasks. While chemo brain is a real condition, clinicians still do not know which cytotoxic agents are responsible, which characteristics make patients vulnerable, and which biologic mechanisms are involved. To date, there have been no large-scale research studies on this phenomenon, so much more research is needed.

However, because chemo brain symptoms can mimic other disorders, it is important that clinicians rule out other medical issues first. For example, the same symptoms attributed to chemo brain can be related to mental or mood disorders, such as anxiety or depression, or a medical disorder, like a thyroid dysfunction. Further, these symptoms can result as a side effect of medications or medication interactions. And while dementia can also create these symptoms, dementia is progressive and chemo brain is not. If the patient truly has dementia, an evaluation by a neurologist may be indicated.

The good news is that chemo brain is not viewed as a progressive condition. Most cancer patients notice improvement over time. Sometimes people see improvement within a few months, but for others chemo brain symptoms continue for a year or two after treatment. Some patients have reported long-term symptoms and may experience lasting effects from their chemo brain.

Tips to Help Your Patients Cope

While unfortunately there is no cure for chemo brain, a multi-modal rehabilitative approach that includes medical, psychological/behavioral, and wellness teaching can make a difference. This can include diet, exercise, talk therapy, and sleep hygiene. However, a multi-modal rehabilitative approach takes time and effort. The goal is to restore functioning and/or learn how to compensate for functions that cannot be restored. The tough reality is that some chemo brain effects may linger; however, patients can learn to live and cope with these limitations.

Here are some of the lessons we’ve learned at our cancer program in helping our patients cope with chemo brain. Step one: Rule out any other medical cause for their symptoms.

After that, be sure that your patient understands what chemo brain is and what he or she can do to diminish its effect on their quality of life. Our providers—both physicians and nurses—include chemo brain as a part of the discussion with patients about potential side effects of the treatment they are receiving. Our social workers, palliative care staff, and registered nurses reinforce that discussion when they meet with the patient. More detailed information about chemo brain is provided through support groups and other presentations to our patients.

It is also critical to be sure your staff understands the implications of chemo brain and how it affects patients, so they can help their patients understand it. We provide that education to staff, as well as to our patients. There ARE techniques that can help:

  • Start slow. We encourage patients not to attempt to try everything all at once, but pick one “thing” to work on and then add on tasks as they go. For example, a first goal might be to simply focus on the amount of sleep they get and set a goal for a consistent bedtime each night. The aim is to try to avoid becoming overwhelmed.
  • Would medication help? While there is no “magic pill” to cure chemo brain, some medications in some situations have shown promise. Anxiety, depression and fatigue are common in patients going through treatment for cancer. Left untreated, these conditions can lead to increased fatigue, difficulty concentrating and focusing, and insomnia. Plus, physical symptoms can seem worse—for example, patients with untreated depression and anxiety report more pain. SSRIs (selective serotonin reuptake inhibitors) and Wellbutrin (bupropion) have been reported to decrease fatigue in some patients and improve their ability to better focus.
  • Walk on. Moderate exercise, such as brisk walking, can help cancer patients cope with stress, fatigue, and depression—all which can contribute to memory problems. Plus, exercise has beneficial effects on cognitive function, perhaps through an increase in blood flow to the brain or through reduction in inflammation.
  • Quality sleep. Normal, quality night-time sleep lends itself to full day-time alertness. Encourage patients to avoid napping during the day, get enough sunlight each day, and practice good sleep hygiene. For example, establish a bedtime routine, avoid caffeine and alcohol before retiring, avoid electronic devices and falling asleep to a TV, read a pleasant book before bed, and use meditation/guided imagery.
  • One thing at a time. Remind patients that while you can multi-task, you can’t multi-focus.
  • Put tools to work. Patients can benefit from supportive tools. This can be as simple as identifying a quiet space to organize tasks (at home and work) or making a basic “to-do” list so that they can cross off items that have been accomplished. Encourage patients to use learning styles that are already working for them. For example, if they learn by writing notes, then write things down. If they are better with visual rather than verbal information, empower them to have visual cues rather than just relying on providing information verbally. Crossword puzzles, word searches, and Sudoku are all activities patients can use to help keep their brains processing. Finally, ask patients to consider what time day of works best for them to tackle their most complicated tasks.

They must redefine what is normal for them now!

References

OncoLink. Cognitive Dysfunction (“Chemo Brain”). May 5, 2016.

CancerCare: www.cancercare.org.


ACCCBuzz contributing blogger Sandy Balentine, MSN, RN, is the Director of Clinical Oncology at ACCC Member Program, The Valley Hospital.

 

Patient Navigation—Process Mapping by Disease Site

By Tricia Strusowski, MS, RN

ThinkstockPhotos-467463476For this patient navigation blog post, let’s talk about a recent hot topic on ACCCExchange, the online discussion forum for ACCC members: At what point in the care continuum do you initiate navigation and support services?

Many cancer programs have a difficult time identifying when to initiate these services. Cancer programs know that staff are duplicating services, but they don’t want anything to fall through the cracks for patients and their families. At busy cancer programs, staff may be challenged to find the time to sit down and work out these details. Plus, getting all the healthcare professionals together for one more meeting can be a daunting task. Cancer programs want to provide the best experience for their patients while utilizing staff efficiently. One way to support this goal is by involved the entire team in creating a disease-site-specific process map to review the continuum of care; discuss staff roles and responsibilities; identify gaps, barriers, opportunities for improvement; and goals of care—all with the patient at the center of the discussion. Simply put: Increasing communication among the team and decreasing duplication for the patient.

Who Should Participate?

Ideally, the team participating in the disease-site mapping process should be representative of the offices and departments that will touch the patient during his or her journey. Keep in mind: You need to include the “worker bees,” the staff who really know the details of the patient flow. Let’s consider a head and neck cancer patient for example. In this instance, the following individuals should be invited to participate:

  • Surgery
  • Medical oncology
  • Radiation oncology
  • Inpatient unit case manager and/or discharge planner
  • Speech/swallowing therapist
  • Navigator
  • Social worker
  • Financial counselor
  • Behavioral health
  • Rehabilitation/Prehabilitation
  • Dental office
  • Others (We all know there is always someone we forget to invite!)

Plan your first session for 1.5 to 2 hours. Admittedly, this may be a challenge to schedule but it can be done, and the results will be amazing. Utilizing a large paper flowchart (i.e.,15 feet long x 4 feet wide), the group needs to talk through and record the process starting at the patient’s earliest point of entry. Each detail must be discussed, including length of time from one episode of care to the next, delays, gaps, and opportunities for improvement. Encourage participants share their goals during the discussion and write everything down!

Revisit & Revise

Process mapping exercises are not a one-and-done experience. It takes several meetings to review and revise the process map. There may be key individuals or a process that are missed in a previous session; no big deal, add them to the group. A great facilitator is key to keep the team on task and keep the discussion moving.

After the entire disease-site process is complete, overlay when you would like the navigator and the support staff to intervene. Remember: the goal is to provide the intervention as soon as possible, hopefully in a proactive manner so that you are “staying one step ahead of the patient.” Incorporate when you would like to initiate the distress screening process, identifying periods of highest distress for the patient/family.

The draft process map is also an excellent tool to share with the disease-site-specific healthcare providers who are often are not aware of all the details, delays, and opportunities to enhance the patient experience. Further, your process map will also be excellent tool for on-boarding new staff and for succession planning. Review and update your process map on a bi-yearly or annual basis.

 Go Team!

I always share that the disease-site-specific team is like a football team; the better all the players understand everyone’s role and how to best support the patient and each other, the stronger the team will be. Every team always wants what is best for the patient. The mapping process is a valuable approach to not just identify gaps or delays in the care continuum, but to also then go the extra mile to identify “what is best for the patient.”

Work smarter not harder; teamwork makes the dream work!

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