Improving Care Coordination for Patients with Lung Cancer: A Look at Best Practices

Patients with cancer often receive care from multiple providers, across many facilities. Because of this multi-layered approach to cancer care, care coordination is essential to supporting quality health outcomes.

In 2016, the Association of Community Cancer Centers (ACCC) developed a tool called the Improving Care Coordination (ICC) Model, that built upon a model created by the National Cancer Institute’s Community Cancer Centers Program (NCCCP) to improve care coordination for patients with lung cancer who are covered by Medicaid. ACCC’s tool includes 12 assessment areas that have a high impact on patient care.

From 2017 to 2018, ACCC cancer program and practice members participated to test the Model at their organizations. Each site participated in data collection and reported on progress or barriers identified throughout the Model’s execution. The ICC Model supports cancer programs and practices in objectively assessing how lung cancer care is provided at their organization. Cancer programs and practices can utilize the Model to measure strengths and areas of improvement while conducting continuous assessment of care coordination, with the goal of providing the highest quality patient care.

Currently, ACCC is updating the Model with new quality metrics and is working with test sites to summarize and share best practices from their experience with the Model. While the Model was originally developed for lung cancer, it can be applied across the cancer care continuum for any disease type.  

Recently, ACCCBuzz had an opportunity to speak with Amy Ellis, chief operating officer at Northwest Medical Specialties, PLLC in Tacoma, Washington, and Wendi Waugh, administrative director of Cancer Services and Ambulatory Infusion at Southern Ohio Medical Center in Portsmouth, Ohio, regarding their experiences implementing the Model at their cancer program. 

ACCCBuzz: Tell us about your cancer program.

Ellis: We are a physician-owned community oncology practice, encompassing 6 clinics, 15 medical oncologists, 20 nurse practitioners, and 27 administrative employees.

Waugh: We are a small community rural (independent) non-profit hospital.

ACCCBuzz: Please describe your location and catchment area?

Ellis: We are in the South Puget Sound of Washington. The population served includes individuals 18 [years of age] and older with oncologic and hematologic diseases. NWMS [ Northwest Medical Specialties] locations are in three counties, King, Pierce, and Thurston, and in the cities of Bonney Lake, Federal Way, Gig Harbor, Olympia, Puyallup, and Tacoma. The location diversity within NWMS exposes great variety within the population served, including socioeconomic status, race, ethnicity, religion, primary language, and rural versus urban living.

Waugh: We are in Scioto County, Ohio. Our catchment area includes 6 counties, 3 are in the state of Kentucky. We serve approximately 80,000 people.

"It is not uncommon for patients to travel 30 or 35 miles to our Hospital, which is the closest in our rural area.”

ACCCBuzz: What does a multi-disciplinary care team look like at your institution?

Ellis: Our lung cancer program has medical oncologists, nurse practitioners, and administrative staff. We are currently putting a nurse navigator in place who will help with scheduling appointments and biomarker testing.

Waugh: Our lung cancer care team is comprised of 2 oncologists, 1 radiation oncologist, 1 cardiothoracic surgeon, and 2 lung navigators.

“I don’t believe the care coordination model should be done in a singular approach.” “I believe part of the value of the model is getting that muti-disciplinary stakeholder group together.”

ACCCBuzz: Describe your cancer program’s care coordination best practices.

Ellis: We have a large research program that encompasses phase 1 to phase 3 trials as well as just-in-time trials. We have research screeners who specifically screen patient charts for potential participants. We try to regularly engage physicians through education, program promotion, and requests for participation on the tumor boards. In addition, we have a non-clinical team (comprised of patient care coordinators) who help us manage high-risk patients such as those experiencing homelessness or those at high-risk for disease progression.

Waugh: We have found that you can spend a lot of money marketing to the general public, but you get more by educating your stakeholder population (ie, ordering providers, people in the field seeing the patients such as nurse practitioners). It is extremely important for them to understand how to screen and what to order. We have had our lung Navigator and Liaison visit providers on a routine basis to seek out referrals to our program.

ACCCBuzz: How do you evaluate and respond to social drivers of health?

Ellis: We have implemented a depression and distress screening (following NCCN guidelines for distress monitoring) and use a tool for screening socioeconomic barriers. The biggest barriers identified have been transportation and housing. Unfortunately, there are not a lot of resources available to impact housing shortages, however we have made strides with transportation. Our social workers help patients coordinate transportation, and if necessary, we have a business Lyft account that will take patients to and from appointments.

Waugh: We primarily evaluate patients through our navigators. We have a phone number (356-Lung) that takes them straight to our navigators. We do not care if you qualify for screenings, we are just interested in getting any calls about concerns with lung health. Our lung health navigator is a respiratory therapist from pulmonology. In addition, we have created gas vouchers for patients who meet certain financial guidelines.

ACCCBuzz: How are patient referrals handled for biomarker testing and/or clinical trials?

Ellis: We have a precision medicine program under our larger research program. We make every effort to test every patient and make referrals to clinical trials as appropriate.

Waugh: Biomarker testing has been a project by our Lung Leadership Team. We use outside labs to perform the tests.

ACCCBuzz: Have you implemented long-term changes after participating in the ICC Model?

Ellis: We have been participating in care models since the Oncology Care Model (OCM). We have a strong commitment to quality improvement and utilizing best practices. For longer term changes, we are seeking a navigator and a RN case manager to help manage and evaluate our progress.

“We can’t advance cancer care unless we participate and learn.”

Waugh: The Care Coordination Model has helped us to create a foundation (a springboard) for the future. We are examining ways to utilize best practices to other applicable disease sites.

Ongoing work to update the ICC Model is made possible by support from Regeneron.

For more information, email Lilly Meier at lmeier@accc-cancer.org.