Category Archives: Education

360-Degree Perspective from the ACCC Institute for Clinical Immuno-Oncology Policy Summit

By Amanda Patton, ACCC Communications

On August 30, the U.S. Food and Drug Administration (FDA) approved the first CAR Chimeric Antigen Receptor (CAR) T-cell therapy, tisagenlecleucel (Kymriah). With this approval of the first cancer gene therapy in the U.S., immuno-oncology took a historic step forward.

Later that same day, in a press release titled, “Innovative Treatments Call for Innovative Payment Models and Arrangement,” the Centers for Medicare & Medicaid Services (CMS) congratulated the scientists and researchers involved in the development of the new treatment, while emphasizing the agency’s  on-going commitment to working with stakeholders on “innovative payment arrangements.”

In hindsight, opening remarks at the ACCC Institute for Clinical Immuno-Oncology (ICLIO) Policy Summit held less than two weeks earlier, seem prophetic:  “Immunotherapy is a hallmark of what’s going on in oncology. . . wonderful, but expensive new therapies, how are we going to make this work? ” said Lee Schwartzberg, MD, FACP, ICLIO Advisory Committee Chair.  Dr. Schwartzberg is Chief, Division of Hematology/Oncology, The University of Tennessee;  Medical Director, The West Clinic.

“Immuno-oncology presents remarkable opportunities and challenges at the same time,” said ACCC President Mark Soberman, MD, MBA, FACS, welcoming participants to the Summit. “We have to figure out how to leverage immuno-oncology for our patients in a very sustainable way in our cancer eco-system.” Dr. Soberman is Medical Director, Oncology Service Line; Chief Physician Executive, Monocacy Health Partners, Frederick Regional Health System.

The by-invitation only, August 18, 2017, ICLIO Policy Summit brought together oncology stakeholders including representatives from patient advocacy groups, pharmacy, research, government, industry, oncology clinician leadership, oncology nursing leadership, and a payer representative to share perspectives on current real-world challenges in immuno-oncology through the lens of:

  • Clinical and Policy Issues
  • Alternative Payment Models
  • Application and Impact of Quality Measures
  • Payer Management of I-O (Immuno-Oncology)
  • Future Challenges and Opportunities

Watch video for comments from ICLIO Policy Summit participants:

360-Degree Perspective

The ICLIO Policy Summit discussion by these diverse stakeholders revealed a 360-degree perspective on the current landscape for the translation of immunotherapy from bench to bedside. Top-level themes from the Summit are highlighted below:

Biomarkers. All stakeholders concur that there is a pressing need to identify biomarkers for immuno-oncology agents in order to address the issue of identifying those patients mostly likely to benefit from being treated with an I-O agent and to help mitigate cost.

Education. New agents are emerging with new mechanisms of action, and combinations and sequencing of immuno-therapy agents are on the horizon. Understanding of side effects, late effects, and long-term effects, and the nuances of immunotherapy delivery for patients in the community continues to evolve. On-going education is imperative, not just for the multidisciplinary oncology team but also for other providers who care for these patients (e.g., primary care, endocrinologists, pulmonologists, radiologists, emergency department staff) and for the patients who will receive these therapies and their caregivers.

Community Perspective. The arrival of new immuno-oncology agents has fundamentally changed the landscape of clinical practice over the past three years. In the community setting, programs need to “take a systematic approach to I-O implementation,” commented community-based provider. P&T Committees must have the capacity to address issues around appropriate use, inventory management, and cost of expensive new and emerging I-O agents to avoid financial toxicity for patients, providers, and institutions.

More Evidence Needed.  I-O is far from plateauing, participants agreed, but more evidence is needed around combination therapy and sequencing of these agents. “We don’t know which combinations are superior and which are superior to single agents,” commented a clinician participant. But that evidence “is coming very quickly,” he added.  “I think combinations are going to be important,” commented a research clinician, “rational combinations,” adding that the “PD-1 pathway is foundational.”

Access to I-O therapies. Prior authorizations continue to be a barrier to access, stakeholders agreed. Pharmacy and PBM participants, in general, indicated that they follow the lead of the NCCN Drugs & Biologics Compendium, but the high-cost of these agents leads to critical pharmacy issues of how to afford these expensive therapies and how the cancer program’s physicians will use them.

Discussion of pathways, pre-authorizations, and “totality of the evidence” for FDA approval (the summit discussion touched on expedited clinical review for I-O based on review of the ‘totality of evidence,’ as is currently the case for FDA review of biosimilar agents)—brought the conversation back to biomarkers. “We need to focus on biomarkers. . . selecting the right patients for the right agents,” emphasized a researcher participant. And he added, “We need multiple modalities because cancer is very clever.”

Clinical Trial Enrollment.  Referencing a recent New York Times article, participants cited the challenge of accruing patients to the many open immuno-oncology trials. At the same time, greater access to I-O clinical trials in the community setting may lessen access barriers to these agents for some patients, commented a researcher participant.

Risky Business: Alternative Payment Models. Discussion of alternative payment models (APMs) focused primarily on the CMS Oncology Care Model (OCM).  Summit attendees participating in the OCM agreed that during the first year of the model, efforts centered largely on “getting all the mechanisms in place”—readying practice infrastructure for OCM requirements. With that accomplished, priorities for OCM practices include reducing inpatient admissions and ER visits, and avoiding adverse events.  However, participants agreed that the need to address issues around high-cost anticancer agents is nearing.  In a risk-sharing payment model, it will be critical to find methods to sustain small and large practices, commented a physician leader.

Stakeholders agreed that a challenge with OCM design is that the episode being measured is too brief; it does not follow the patient’s entire cancer journey. Outcomes such as cure or disease-free survival, for example, are not included in the OCM.  “The model looks at cost, not value,” noted a participant.

Still, the OCM provides a path toward demonstrating attributes of patient-centered care that are components of the new value-based payment models, participants said.

Quality Measures & I-O. Coming to consensus on quality measures in oncology remains a challenge. Patient advocate stakeholders pointed to the study by Basch and colleagues presented at ASCO 2017 showing that just by tracking patient-reported outcomes (PROs), patients lived longer. From the patient advocate perspective quality measure concerns are multifold, including:

  • Tension between the driving trend in oncology toward standardized measure sets (pathways, etc.) and precision medicine, i.e., the need to support appropriate variation in order to individualize patient care.
  • Current patient satisfaction measurement tools that do not assess what really matters to patients (e.g., quality of life and outcomes).
  • Quality measures that assess process (much of which is already being done), rather than outcomes measures that would be tangible to patients (e.g., staying out of the hospital).

In response, patient advocacy groups are developing their own quality measures based on what patients’ say is important to them, including not just clinical measures but quality of life measures such as disruption to work, childcare, and transportation to treatment.

Payer Management of I-O. As the current healthcare reimbursement landscape continues to evolve, key concerns identified during the ICLIO Summit were:

  • The need for biomarkers for patient selection to ensure those most likely to benefit from the I-O therapy will receive it and those who won’t, don’t.
  • The need for the healthcare system to be more nimble and adaptable in “looking at good data.”
  • One of the biggest challenges for clinicians is variation in coverage under different health plans. As an example, a provider sees five different patients with the same cancer type, each with a different health plan, each with its own coverage options and requirements. The end result: guidelines to reduce variation are not working, commented a health system executive.
  • Prior authorizations creating barriers to access and uncertainty for patients, providers, and practices. “We’re taking on risk with . . .value-based payment, but we’re still saddled with prior authorization. Maybe it should be one or the other,” said a clinician leader.
  • Managed care organizations and others are looking at how to bundle oncology products into trend management pools.

Looking to the Future

The final discussion block looked to the future. In a lightening round, Summit participants were asked to share their perspectives one key challenge or opportunity for immuno-oncology in the near future—summed up in a sentence or two.  Their responses offer a final 360-degree look ahead at real-world issues facing immuno-oncology:

  • We need to develop a quality measure that is “patient returns to functional status.”
  • In the value discussion, there is realistic, and then there is reality. A lot of what becomes value is tied to your resources. [Many times] in medical situations, that’s not taken into consideration.
  • Future treatment decisions informed by biomarkers and life circumstances.
  • View all navigators as integral parts of the cancer care system.
  • Adapt [the] delivery system to be more nimble to adopt major advances.
  • We need to look at real-world evidence for comparative effectiveness. We have to go beyond the regulatory system to really understand the value in the community that each agent brings.
  • Will we have enough doctors, nurses, social workers, and navigators to treat patients with these complex therapies?
  • We need to develop and implement patient-reported outcomes, and we need to understand the real cost of care.
  • Between academic programs, the federal government, [industry], and the community, we need to get more serious around biomarker development and who is most likely to benefit from expensive therapies and those not likely to benefit.
  • Clinical trials. . . how can we bring clinical trials to community hospitals? We need a process to open clinical trials [so that the community can] benefit from access to these drugs early on.
  • Evidence generation. . . stakeholders need to generate evidence.
  • Preparing the nursing workforce [to move] from a disease-state specific [care model] to a more biomarker-driven model.
  • Form follows function; if the future of medicine is biomarker driven, then resources have to be organized along that line.
  • Greater investment in analytics so that we can get more nimble feedback; greater degree of analytic support.
  • Establish and maintain a national registry to capture and analyze data from real-world care.

In closing the ICLIO Policy Summit, Advisory Committee Chair Lee Schwartzberg, MD, FACP, thanked participants: “We come from different points of view, but we have common ground. . . . Communication is the way we’re going to go forward with new therapies in [our] complex [healthcare] system.


The ACCC Institute for Clinical Immuno-Oncology is the only comprehensive initiative to prepare multidisciplinary cancer care providers for the complex implementation of immuno-oncology in the community setting.  View ICLIO’s robust resources, webinars, education offerings, and more, on the ICLIO website accc-iclio.org.

Staying the Course: The Role of Oral Oncology Nurse Navigators

By Virginia Vaitones, MSW, OSW-C

The development and use of oral agents in treatment for oncology and blood disorders has exploded over the last decade and half. Today, these agents bring many benefits to patients and cancer care staff, but along with those benefits come challenges.

Then . . . and Now
Thinking back to 2001, for example, when capecitabine, the first oral chemotherapy for the treatment of metastatic colorectal cancer was approved, Medicare covered 80% and the beneficiary’s co-insurance was 20%. A patient could simply take the prescription to the local pharmacy and get it filled. The relatively modest financial impact and the ease with which the patient could access the medication made me excited about the use of oral agents. And at the time, there was much discussion about oral agents being the treatment of choice in the future.

Nearly two decades later, we now have more than 50 U.S. Food and Drug Administration-approved oral anticancer agents.  Over that same time span, as we all know, our healthcare landscape has become increasingly complex, as have our anti-cancer therapeutic regimens. Currently, capecitabine is 1 out of only 5 oral chemotherapy that is covered by Medicare at 80%. Patients and providers today often face challenges in accessing and affording costly new oral agents. Patient understanding of and adherence to complex treatment regimens can also be a barrier to effective treatment. As a result, ensuring quality care for patients receiving oral agents often requires a coordinated effort by innovative and creative cancer practices and programs.

The September/October edition of Oncology Issues highlights two such programs. One program is a large physician practice in central New York with an in-house dispensary; the other is a large outpatient hospital network serving two states, Kentucky and Southern Indiana, also with an in-house dispensary. The first step for both was consulting with their stakeholders to identify how care needs to be delivered and monitored. In both instances, on-going patient support and education were identified as key in establishing trust and compliance with the patient and their caregivers. The answer for both programs? Creating an oral oncology nurse navigator program that ensures care coordination, provides a single point of contact for patients and providers, and has led to improved patient care and satisfaction.

As we engage in the complex delivery system of value-based, patient-centered care, the Association of Community Cancer Centers continues to develop tools and resources for cancer care providers seeking to implement or enhance their oral oncolytic programs. Explore peer-to-peer resources, including webinars, white paper, and patient education materials, available through the ACCC Education initiative Steps to Success: Implementing Oral Oncolytics.

Approximately 25-30 percent of the new cancer treatments in the pipeline are oral agents; cancer programs and physician practices will continue to need a well-coordinated team effort to ensure patient safety and satisfaction.


Virginia Vaitones, MSW, OSW-C, is a past president of the Association of Community Cancer Centers (ACCC)  and the Association of Oncology Social Work (AOSW). She is currently serving as chair of the ACCC Editorial Committee. 

The 34th ACCC National Oncology Conference, Oct. 18-20, offers the Oncology Pharmacy Education Network (OPEN) Pre-Conference, including a session on a comprehensive, collaborative, pharmacist-led oral chemotherapy program. Learn more here.  View the full conference agenda.

Dietitian as Navigator: A Winning Combination

By Kelay Trentham, MS, RDN, CSO

Compass pointing at answers-SMALLIn cancer care, the use of patient navigators has grown substantially over the past decade. In 2012, the American College of Surgeons Commission on Cancer added Standard 3.1 requiring that accredited programs have a patient navigation process in place.

While the navigator’s role and responsibilities may vary from institution to institution, clinical navigators typically:

  • assess patients’ clinical, financial, spiritual, and other needs;
  • ensure patients are referred for appropriate supportive care services such as financial counselors, social workers or psychologists, palliative care, and rehab services;
  • provide needed patient education on their disease and its treatment;
  • assist patients in overcoming barriers to care; and
  • assist in discharge and advanced care planning.

Given this list, it may come as no surprise that nurses and social workers are often in navigator roles. Some programs may also employ non-clinical navigators who assist patients with some services, as is the case with the American Cancer Society’s resource navigators, who educate patients about ACS and other community resources. Patient navigation often involves a variety of multidisciplinary team members, with nurse or social work navigators referring patients to physical therapists or dietitians for their specialized care, for example.

For diagnoses that require intensive nutritional support, such as head and neck or esophageal cancer, a Registered Dietitian Nutritionist (RDN) can effectively serve as a patient’s principal navigator, as these patients may see the RDN as often, if not more often, than other team members. In initial medical and radiation oncology consults, these patients are often told that they will need a feeding tube. For many patients, the idea of having or using a feeding tube can be frightening and overwhelming. Prior to receiving feeding tube education, patients may have many concerns such as that the tube is very large and cumbersome, how it might impede normal daily activities, that tube placement is permanent, or that they or their caregiver(s) won’t be able to learn how to use it. Meeting with an RDN for immediate education can allay any fears and concerns about this component of their care plan and reduce distress. In addition, the RDN can reassure patients and caregivers that he or she is available to assist with any questions about using the tube throughout the course of treatment. Further, the RDN navigator can assure the patient that their experience and training places them in a unique position to best advocate for the patient with respect to nutrition support issues.

The RDN’s knowledge base makes this member of the cancer care team an excellent fit for ensuring coordination of care with a patient’s home infusion agency. An RDN navigator can work with the medical team to ensure proper documentation so that enteral feedings are covered by insurance, assist patients with locating donated tube-feeding supplies and formula in the event of limited or a lack of coverage, and work with pharmacy services to get medications converted to crushable or liquid forms for use in feeding tubes. In addition, the RDN navigator would continue to see the patient regularly during the transition from tube feeding back to an oral diet, coordinating care with the speech therapist or surgeon as needed. For example, after esophagectomy, patients experience significant changes in oral diet tolerance and may require considerable education and coaching to adapt to their “new normal.”

Much like the nurse or social worker navigator, the RDN would refer patients to other disciplines when needed, such as to an RN for education about port placement, to a social worker or financial counselor for financial concerns, or to rehabilitation services (physical and/or lymphedema therapy). For some patients, intensive nutrition support may be required from before treatment until long after treatment is completed, making it a central component of care that an RDN is well equipped to navigate.

For cancer patients requiring intensive nutritional support, having an RDN serve as the patient’s navigator can be a winning combination, improving care and the patient experience.


ACCC member Kelay E. Trentham, MS, RDN, CSO, is a past chair of the Oncology Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics. She is currently an oncology dietitian at MultiCare Regional Cancer Center in Tacoma, WA.

For more, learn about a weekly outpatient nutrition clinic for head and neck cancer patients developed by 2014 ACCC Innovator Award winner Beaumont Cancer Institute, Royal Oak, MI.

Taking Lung Cancer Screening on the Road

Carolinas HealthCare System, Levine Cancer Institute will be honored with a 2017 Innovator Award at the ACCC 34th National Oncology Conference in Nashville, in October, for their development of the first mobile CT unit for lung cancer screening in the U.S., bringing state-of-the-art technology to rural communities. 

By Mellisa Wheeler, BSW, MHA, and Derek Raghavan, MD, PhD

As the oncology community is well aware, despite improvements to the early diagnosis, systemic immunotherapies, and gene-directed treatments of lung cancer, mortality rates remain high for this disease. A number of factors underlie this high death rate: the nature and natural history of the disease itself, poor access to care among continuing and recent smokers, lack of health education, fiscal and cultural issues, social stigma, and geographical isolation, among others. When patients present with Stage 1 (localized) lung cancer, surgical cure is possible in more than 50% of cases; when patients present with metastatic disease, for practical purposes, cure is highly unlikely.

Given that geographical isolation and barriers to care access are such important determinants of outcome, the Levine Cancer Institute sought to develop a program that would help to identify and eliminate barriers in high-risk and underserved communities.

Supported by a grant from the Bristol-Myers Squibb Foundation and in collaboration with Samsung and Frazerbilt, Levine Cancer Institute has developed the first mobile CT lung cancer screening unit in the United States.

Our mobile screening vehicle consists of a conventional low-dose Samsung CT unit mounted onto a robust, well-sprung truck body, with a built-in clinical space.  Initial testing has demonstrated the fidelity of the unit, as well as the lack of impact of on- and off-road transportation on the functionality and image quality of the scanner.

We have also created a mechanism for electronic image transfer for reporting at a central location by the staff of partner radiology groups like Charlotte Radiology, Stanly Imaging, and Shelby Radiological Associates. Watch our video and learn more.

The entire program, one of several lung cancer projects of different types supported by the Bristol-Myers Squibb Foundation, is directed toward underserved and under-privileged populations. Our program includes several social components, including outreach and education on lung cancer screening for local physicians, nurse navigation and education, patient outreach with smoking cessation programs, and meticulous follow-up to avoid the loss of patients with identified lesions. Carolinas HealthCare System, the largest safety-net health organization in the Carolinas, has committed to providing optimal care to any patients shown to have lesions requiring further investigation, irrespective of their ability to pay; this care includes follow-up and repeat scanning; biopsy; and surgical, radiation, or systemic treatment.

We have already identified cases of early stage disease that have been directed towards definitive and hopefully curative treatment. In addition to the potential to improve patient outcomes, surgical treatment of early stage lung cancer is far less costly to the community than palliating the disease via systemic therapy. Through our program, we anticipate much improved outcomes for lung cancer treatment at a substantially reduced cost in the community.


Mellisa Wheeler, BSW, MHA, is Disparities & Outreach Manager, Levine Cancer Institute, and Derek Raghavan, MD, PhD, FACP, FRACP, is President, Levine Cancer Institute, Carolinas HealthCare System.

Hear details on the Levine Cancer Institute lung screening program and see their mobile CT unit at the ACCC 34th National Oncology Conference in Nashville, Oct. 18-20. Browse the full agenda.

 

Chemotherapy Drug-Specific Education: Putting Information at the Patient’s Fingertips

As we continue to better understand the many diseases encompassed under the name, “cancer,” we are also seeing an increase in the number and complexity of anti-cancer treatments. These exciting advances are taking place while cancer programs are striving to empower patients with education about their diagnosis and treatment journey and continually improve the patient experience of care. In this guest blog post, Dr. James Weese, vice president, Aurora Cancer Care, describes his program’s 2017 ACCC Innovator Award winning approach.

By James Weese, MD, FACS

The Challenge
Oncologists, nurses, and other cancer care staff across the country work tirelessly to find the best way to deliver a patient’s treatment plan, including the type of chemotherapy treatment recommended and side effects patients may experience. In the aftermath of hearing the words, “You have cancer,” the life-changing ripple effects of that diagnosis can make it challenging for patients and their families to absorb all the details and fully understanding the treatment plan that’s ahead.

At Aurora Cancer Care, we wondered how we could provide better information in a consistent manner to patients across our large geographical area. Information that could be delivered in the office and reviewed in the comfort of the patient’s home. We offer cancer care in 19 communities from the Wisconsin-Illinois border all the way up to Marinette, Wisconsin, and diagnose nearly 8,000 new cases each year.

That’s a lot of people who need to hear consistent messages and in a way that’s convenient for them.

Our team at Aurora Cancer Care set out to address this challenge while creating a more meaningful experience for patients and their families. Under the leadership of Kerry Twite, MSN, RN, a certified oncology clinical nurse specialist with Aurora Cancer Care, a series of more than 125 educational videos were developed to provide a more personalized experience to patients. Four key principles guided the development of the video series:

  1. All patients need basic information about chemotherapy prior to treatment.
  2. Most drugs today are given in combination with other drugs.
  3. Patients want to share educational information with family and friends who may not be able to attend each appointment.
  4. Patient education from nursing teams can vary depending on multiple factors, including available time, location, and number of other potential interruptions during the session.

The Video Solution
With these tenets in mind, our team developed more than 125 chemotherapy educational videos featuring Aurora Cancer Care physicians, nurses, and other staff. Each education video a patient receives includes three videos:

  • First, a chemotherapy video explains basic principles of chemotherapy, including how it is administered (oral or intravenous), the different types of drugs, and potential side effects and complications.
  • Then, a video provides specific information about each drug the patient will receive.
  • Finally, a “Cancer SOS” video, details for patients how to manage their care at home and when to call their physician or go to the emergency room.

All the educational videos are housed on a password-protected website. When patients receive their treatment plan, they are emailed a link and password to the specific drug treatment that they will be receiving. Patients can then watch the video before their next appointment in the comfort of their home, and they can also share the video with family and friends who may have questions. Patients can then come to their next appointment with specific follow-up questions. Patients and families can access and watch each video as many times as they wish.

Learn more on our education program in this video.

Results
Patients have shared with our nursing team how helpful they’ve found these videos in preparing themselves (and their families) for the road ahead. More engaged patients mean higher patient satisfaction scores, and we’ve certainly seen that too, though it’s very early in the roll-out of the video series to see a major shift.

Our video series has also allowed nursing staff to focus on other educational tasks during the patient’s appointment while still ensuring consistent educational information for patients is provided throughout the treatment process.

At Aurora Cancer Care, our focus rests solely on the delivering the best care possible to patients throughout our region and helping them fight and overcome the disease. We are honored to be named the recipient of a 2017 ACCC Innovator Award for our patient educational video series, and hope it might inspire other cancer centers to explore similar educational tools for patients.

Learn more about how we developed our video series during our presentation at the ACCC 34th National Oncology Conference, Oct. 18-20, in Nashville, TN.


James Weese, MD, FACS, is vice president, Aurora Cancer Care, Milwaukee, Wisc.

Meet all of the ACCC 2017 Innovator’s at the ACCC 34th National Oncology Conference in Nashville. Browse the full agenda. Early bird registration rates run through Monday, August 21.

Providing Support to Oncology Professionals

By Virginia Vaitones, MSW, OSW-C

Hands offering supportHealthcare professionals are known for hiding their grief. There is an unspoken (though outdated!) code that we must be strong. Or, put another way, that we just need to get used to it.

But with increased recognition of the high risk for burnout among healthcare professionals, this “old code” is coming under scrutiny.

Writing about “professional grief,” Elizabeth Clark, PhD, ACSW, MPH, former executive director of the National Association of Social Workers observes that “professional grief is generally hidden grief, grief that is internalized and not openly expressed . . . . There’s no natural outlet and demands of work overshadow it.” Grief that is stuffed away can and will accumulate which can lead to helplessness, hopelessness, anger, detachment, and burnout. Read more.

Serving on the frontlines of care, oncology nursing staff often build relationships with patients (and their families) who they often see for weeks and months. Not surprisingly, research has shown these healthcare professionals may be at risk for burnout syndrome.

At Sarah Cannon Cancer Institute at Johnston-Willis Hospital in Richmond, Virginia, the chaplain and social worker knew that “. . . more needed to be done to provide intentional, self-care opportunities for staff allowing them to break through layers of grief and become emotionally and spirituality stronger.”  With input from the oncology nurses serving on a bereavement committee, the program has developed the Reflection Service for staff only. In their article in the current edition of Oncology Issues, “Normalizing Feeling of Grief and Loss in Oncology Nurses,” Jennifer Collins, MDiv, MS, BCC, director of Pastoral Care at HCA, CJW Medical Center, and Sandra Tan, MSW, LCSW, ACHP-SW, a licensed clinical social worker at Sarah Cannon Cancer Institute at Johnston-Willis Hospital, share how their program has created a “safe space” for oncology nurses to reflect, share, and grieve in their cancer center. Read their story.

Those of us working in cancer care know that in the coming years, we are facing projected workforce shortages while our aging population will bring an increase in cancer diagnoses.  As the field of oncology grapples with these challenges and plans for the future, I think we can all agree that replacing the “old code” with a “new code” addressing and mitigating the risk of burnout among healthcare professionals is essential.


Virginia Vaitones, MSW, OSW-C, is a past president of the Association of Community Cancer Centers (ACCC)  and the Association of Oncology Social Work (AOSW). She is currently serving as Chair of the ACCC Editorial Committee. 

Creating a Navigation Intake Assessment Tool

By Tricia Strusowski, MS, RN

Compass pointing at answers-SMALL      “I want to be aware of the navigator and support services as soon as possible.”

This is a frequent response from patients when asked about the optimum point in the cancer care journey to learn about navigation and support services.

And yet, during a first visit (or intake interview) with a patient, navigators may question how much to review. Where is the balance between too much information and not enough?  Based on my experience in care coordination and patient navigation, here’s my perspective on creating and using an intake assessment tool.

Number 1 Rule:  Assess if the patient is ready for this discussion. First, provide support. Let the patient and his or her family take lead in the conversation. Listen. Then, based on your assessment, ask the patient and family if they are ready to review the support services and their specific needs. Once you receive their permission, you can then initiate the intake assessment process.

Each cancer program should have a consistent process for assessing and educating patients and families about the cancer program and support services.  A well-crafted intake assessment tool can be used for all cancer disease sites and should include the following:

  • Role of the navigator and the support staff at your cancer center
  • Mini assessment of immediate support service needs
  • Preferred learning style for education
  • Questions that prompt a conversation on what the patient knows about his or her cancer
  • Questions to elicit from the patient specific concerns, goals, and family concerns
  • Family, medical, and surgical history
  • Mini symptom and behavior risk assessment
  • A listing of national and community resources (usually included in patient’s treatment journal).

Gathering this essential information at the time of your initial visit with the patient will establish a strong foundation for the multidisciplinary team. The navigator’s assessment process is an opportunity to begin the discussion about goals of care and/or goals of their treatment—a pillar for providing patient and family-centered care. Further, identifying patients’ preferred learning style and using it across the continuum sets them up to succeed in understanding their cancer and treatment plan. This information can be shared at tumor conferences, multidisciplinary meetings, huddles, or via email if a secure environment is established.  It is also vital to support the navigator role in educating the patient and family consistently, as well as providing an important resource tool for navigators who may be called on to cover for a colleague. An assessment tool is a key component for a consistent foundation to navigation, but health literacy training and patient education teach-back methods can enhance the process and support staff success in educating patients and their families.

Assessing the immediate needs of the patient and family, while providing education and support, establishes a patient-centered approach and lays the groundwork for a strong bond between the patient, family, the navigator, and the support services.

View a sample navigation intake assessment tool. You are welcome to revise this tool as needed for your cancer program.


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

The upcoming 34th ACCC National Oncology Conference, Oct. 18-20 in Nashville, Tenn., features multiple sessions focused on optimizing patient navigation services to improve the patient experience, and more. View the conference agenda.

Turning on the Light Switch

June is Cancer Immunotherapy Month, shining a spotlight on advancements in immuno-oncology. 2017 ACCC Institute for Clinical Immuno-Oncology Innovator Award winner Oncology Specialists S.C. at Advocate Lutheran General Hospital has been delivering immunotherapy for cancer for more than six years. For highlights on how they’ve developed their program and how “Turning on the Light Switch” helps their providers and patients talk about managing immune-related toxicities, read on.

by Ann McGreal, RHanging BulbsN

For more than 30 years the world of oncology nursing and the patients we care for has been bound by the expectations of the known effects of chemotherapy on the human body. While these toxicities can be difficult and, at times, even life threatening, for the most part they are predictable. As experienced oncology nurses, we know that after a certain number of days the patient blood counts will likely drop. Our patients being treated with chemotherapy anticipate that they may experience nausea, diarrhea, bone pain, and other side effects. For the most part, with chemotherapy we can expect a logical start, progression, and end to toxicities.

Immuno-Oncology Brings a Paradigm Shift
However, the new dawn of immuno-oncology and the rapidly increasing use of immunotherapy for cancer have upended not only our approach to supporting oncology patients, but also how we approach the toxicities of treatment.

Our practice, Oncology Specialists at Lutheran Advocate General Hospital, in Park Ridge, Illinois, has been on the cutting edge of using immunotherapy for melanoma treatments from the beginning. We were among the highest accrual sites for the original ipilimumab clinical trials. Then, in 2011, immunotherapy took its first big step into the limelight with the FDA approval of ipilimumab for the treatment of Stage IV melanoma. The demand on our clinic for ipilimumab increased greatly.

Initially, our practice was able to deal with the need to think about symptom management in a different way because we were caring for a small population of patients—all in the melanoma space. However, in 2014, with the dawn of PD-L1 checkpoint inhibitors that all began to change. Today, the potential for this class of drug seems unlimited, with more than 500 current studies underway in the U.S., and new indications and approvals occurring on what seems like a daily basis.

Educate. Educate. Educate.
As we implemented immunotherapy in our practice, our nursing team took on the challenge of how best to educate both staff and our patients on the mechanism of action for these new therapies, as well as their potential toxicities.

We quickly learned that peer-to-peer education was the most effective way to help our medical staff develop a better understanding of immunotherapy. We also found that the real challenge lay in accepting that immunotherapy for cancer requires a different way of looking at the total treatment picture. To implement this new treatment paradigm, we needed to better educate our patients so that they had a clear understanding of how immunotherapy differed from traditional chemotherapy and why early reporting of toxicities is so important. This meant we had break through long-held beliefs such as, “everyone gets sick during cancer treatment” and “I should just ‘tough it out’ or they will stop my therapy.” We needed our patients to understand that with immunotherapy just “tough it out” can be a deadly mindset. Patients on immunotherapy need to partner with their providers and report any toxicities early so that their healthcare team can work quickly to resolve the issue.

Flipping the Switch
With this need in mind, we created a set of education tools built around the analogy of the patient’s immune system functioning like a light switch. The immunotherapy treatment turns the switch on. If the treatment starts causing toxicities, the patient’s body cannot turn the switch off by itself. Unless the toxicities are reported, the affected system (the light) will burn out. Today, these education tools and discharge instructions are the backbone of our immunotherapy program.

Next Step: Incorporating into Our EMR
With our staff education and training on managing immune-related toxicities and patient education in place, we looked at processes to ensure cohesive documentation in our EMR so that an on-call physician or covering nurse could easily pick up the treatment thread and assist patients. This not only led to the development of templates but also a standardized treatment plan for immune-related toxicities, including the use of corticosteroids.

At the ACCC 34th National Oncology Conference in October, we’ll be presenting a more in-depth look at how we have developed and grown an immunotherapy program at our practice.  We hope you’ll join us in Nashville.
________________________________________________________________
Ann McGreal, RN, is an Oncology Nurse Clinician at Advocate Lutheran General Hospital in Park Ridge, Illinois.

Read more about upcoming ACCC 34th National Oncology Conference here.

Navigation Caseload Quandary?

Learn about 2017 ACCC Innovator Award winner USA Mitchell Cancer Institute’s homegrown Oncology Navigation Acuity Tool.

By Rev. Diane Baldwin, RN, OCN, CBCN, and Meredith Jones, MS, BSN, RN

FinalSealUnfortunately, nurse navigation services are typically non-revenue generating, necessitating a cost/benefit evaluation of these services for many programs. To justify nurse navigation in this new era of value-based care, we must define appropriate caseload volumes through risk stratification, and determine how best to allocate nurse navigation time and resources among those caseloads.

How Best to Measure & Define Acuity?
Acuity tools have been used in healthcare for decades and have proven successful as a means of determining staffing needs, improving patient care, and controlling costs.  Most acuity tools score patients on a scale of specific attributes. For nurse navigation programs, an acuity tool can be used to determine caseloads and aid in more efficient nurse navigator caseload management.

At USA Mitchell Cancer Institute, our nurse navigators, known as Clinical Care Coordinators, maintain a caseload of approximately 175 patients. However, as we identified more patients needing navigation services, we recognized the need for an acuity tool specifically for caseload management.

As we researched acuity tools, we found limited options related to oncology nurse navigation. Each of the tools we identified was specific to a facility, and was either used to determine overall staffing or focused specifically on the amount of time spent with patients.  We believed that a more generalized tool, including more patient factors, was needed to accurately determine patient acuity. Therefore, the USA Mitchell Cancer Institute began developing an Oncology Navigation Acuity Tool, universally designed to benefit our practice, while also allowing for use and adaptation by other cancer programs.

More Than Just a Number
USA Mitchell Cancer Institute’s goal was to develop a tool that measures a patient’s acuity through a holistic lens. As cancer care providers know, each patient’s navigation needs depend on a variety of factors. Our Oncology Navigation Acuity Tool considers 11 factors that we identified as directly correlating with patient resource utilization and, therefore, acuity level.  Each factor is reviewed individually to determine the acuity score, placing less emphasis on cancer type and stage, and more emphasis on overall patient context. For example, two patients with the same type and stage of cancer, receiving the same treatment, may present with different comorbidities and levels of family support, resulting in two very different acuity scores.

An inherit weakness in most acuity tools is that the “score” assigned to the patient determines overall acuity. However, we know that our patients are more than just a number.  Standardized tools often fail to identify important elements needed to address individual patient needs. Therefore, our Oncology Navigation Acuity Tool includes a 12th factor in determining a patient’s acuity: The clinical assessment of the nurse navigator.  This factor is essential to assessing the “whole patient” and our aim of providing holistic care.  Our nurse navigators use the 11 factors of Oncology Navigation Acuity Tool as a guide to assess the acuity of the patient and combine this with their overall clinical assessment, for a final acuity score.  Ultimately, our nurse navigators, may elect to change the acuity level based on their assessment of the individual patient.

Putting the Tool to Work
The Oncology Navigation Acuity Tool allows us to easily assess the needs of each navigated patient prior to caseload allocation and to quickly determine the level of navigation the patient will need. The tool has also guided managerial decisions to adjust caseloads based on acuity rather than patient count alone.  Further, we’ve utilized this tool for both quality and process improvement to study the varied needs of patients among the acuity levels, and to determine the effect of accurately navigated patients on system utilization and cost.

In our presentation at the ACCC 34th National Oncology Conference, October 18-20, in Nashville, TN, we’ll share more on how using this low-cost, simple to implement tool has resulted not only in a cost-effective, efficient means of refining navigation utilization, but also in the delivery of more personalized, comprehensive, improved quality of care for our navigated patients.

We look forward to seeing you in Nashville!


Rev. Diane Baldwin, RN, OCN, CBCN, is Manager, Quality Assurance, and Meredith Jones, MS, BSN, RN, is Director, Quality Management, at the USA Mitchell Cancer Institute.  

From ASCO to ICLIO to Your Program—Immunotherapy Moves into the Community

By Amanda Patton, ACCC Communications

Once again immuno-oncology (I-O) was center stage at this year’s American Society of Clinical Oncology (ASCO) Annual Meeting (June 2-6, 2017) where more than 250 presentations featured checkpoint inhibitors. Currently, six immune checkpoint inhibitors have received FDA approval for more than nine cancers, with more than 1,000 studies in progress.

On June 2 at ASCO, two pre-eminent immunotherapy investigators provided perspective on the rapidly evolving immuno-oncology landscape with a look back and a look to the future.  During their presentation, “On the Shoulders of Giants: Historical Approaches to Immunotherapy in Solid Tumors,” James P. Allison, PhD, of The University of Texas MD Anderson Cancer Center, and Suzanne L. Topalian, MD, of the Bloomberg-Kimmel Institute for Cancer Immunotherapy, touched on some of the critical challenges the oncology community faces with these new and emerging therapies, including:

  • How to deal with the flood of information from clinical studies
  • The need to better understand the biologic processes underpinning of side effects of these new therapies
  • The imperative to identify biomarkers.

Read highlights from their presentation in this ASCO Daily News article.

ICLIO’s Evolving Role—Supporting Integration of I-O into Practice
Just as insights from ASCO 2017 will continue to ripple throughout the broader cancer community for weeks and months to come; the wave of new approvals and indications in immuno-oncology will continue to spread from academic settings into community programs and practices, where it is estimated that 85% of the nation’s cancer care is delivered.

Since its inception more than two years ago, the ongoing mission of ACCC’s Institute for Clinical Immuno-Oncology (ICLIO) is to create education, resources, and tools that provide practical, real-world support for multidisciplinary team members engaged in bringing immunotherapy to patients in their communities. Hear about ICLIO’s growth and latest initiatives in this ASCO Post interview with ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, Chief, Division of Hematology Oncology; Professor of Medicine, The University of Tennessee; The West Clinic, PC.

ICLIO In the Community
In 2017, ICLIO launched two exciting new programs—ICLIO Visiting Experts and Case Studies in Immuno-Oncology—that bring clinicians with immunotherapy expertise out to providers in the community.

“It’s an area that ICLIO is spearheading,” said ICLIO Visiting Expert Jarushka Naidoo, MBBCh, Assistant Professor of Oncology at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University and Bloomberg-Kimmel Institute for Cancer Immunotherapy.  With the ICLIO Visiting Experts program, “Investigators such as myself who are particularly interested in immunotherapy can actually go to community providers and give our hands-on experience of how we give these agents, what are the common side effects that we see, and what are some of the ways we’ve gotten around some of those particular considerations. We’re able to interact with the workshop participants one-on-one and talk about specific cases they’ve managed, some challenges they’ve had, and how we might have dealt with that from an academic perspective.”

Learn more in this Hem/Onc Today interview with Dr. Naidoo:

For the just-launched Case Studies in Immuno-Oncology, an ICLIO faculty member will travel to an ACCC-member program for a 60-minute case-based tumor board discussion on immunotherapy treatment decision-making and the management of associated immune-related adverse events. Learn more and apply.

Immuno-Oncology Advances from ASCO 2017
Access top-level takeaways on advances in immunotherapy for cancer from the ASCO 2017 Annual Meeting in this  ICLIO webinar presented by Lee Schwartzberg, MD, FACP.  View webinar.

View all ICLIO has to offer by visiting accc-iclio.org.


Editor’s note: This post was updated on 6/28/17.