SEIZING THE OPPORTUNITY TO IMPROVE CARE
In a recent study, 401 members of the Academy of Oncology Nurse Navigators were surveyed, and approximately half of the respondents reported that their own knowledge of cancer rehabilitation and appropriate referrals for care was relatively low.8 In the same survey, 90% of participants responded that cancer rehabilitation services were important.8 Clearly, while nurses value cancer rehabilitation care, many have not had specific training in this area of medicine. In the CoC model, the cancer committee would include a cancer rehabilitation specialist who would oversee staff training and implementation of physical assessments and interventions associated with prehabilitation. Similarly, a mental health professional is required to oversee, but not necessarily personally perform, distress screening (Standard 3.2) and report the results to the cancer committee.9 Ideally, in some settings nurses should be trained to perform prehabilitation physical assessments such as the QuickDASH and screening upper extremity evaluations, and trained to perform early distress screening.
As cancer prehabilitation has begun to evolve and is increasingly becoming part of high-quality care, initial screening has clearly become an important step in the cancer care process. Furthermore, because cancer and its treatments may cause both emotional and physical issues in survivors, dual screening for physical and psychological impairments is crucial.10 These baseline screenings allow for an early understanding of the patient’s physical, psychological, and functional impairments, and provide information for directed interventions that may prevent or limit future impairments and/or disability. These pretreatment screenings are also essential to establishing objective baselines that demonstrate individual patient and survivor population outcomes while at the same time offering an opportunity to demonstrate lower health care costs and higher employment rates in survivors who are able to function at a higher level throughout and beyond their acute oncologic treatment (Figure 3).
Delays in cancer treatment may adversely affect prognosis, therefore prehabilitation assessments and interventions should be carefully timed to use whatever window of opportunity is available before treatment begins. Even if the time before treatment begins is very short, prehabilitation provides an opportunity to gather the baseline status of the patient, to provide interventions that can be utilized throughout treatment, and to encourage and empower the patient. In this way, whatever time is available to patients with new cancer diagnoses before treatment begins is utilized to enhance their physical, emotional, and functional health outcomes. For example, encouraging patients to begin an exercise program that can be carried into the treatment phase right away is beneficial, and even if the therapeutic benefits of exercise are not immediately demonstrable, it still may improve a number of outcomes including mood, comfort, and endurance. Moreover, starting the exercise program immediately may also improve adherence not only to physical activity recommendations but also to acute treatments such as chemotherapy. Similarly, teaching patients specific strategies such as meditation or guided imagery to decrease stress provides them with tools they can use within days as they prepare for surgery or other upcoming treatments.
Whether prehabilitation is reimbursable by third party payers depends on many factors including which assessments and interventions were performed, who performed them, and in the setting in which they took place.11 For example, interventions such as smoking cessation, anxiety reduction, and the identification and treatment of physical impairments are often covered by third-party payers. Notably, identification and treatment of physical impairments are typically covered only when provided by specialists such as physiatrists and physical, occupational, and speech therapists.
Direct reimbursement for nursing care, including navigation, is more challenging. Even when direct reimbursement for nursing care is not available, there are important ways to demonstrate economic value. For example, patients who are entered into a supportive prehabilitation protocol right after diagnosis may be more likely to receive their total cancer care at that institution. Even if they are intent on getting a second opinion, the value of having patients immediately bond with their health care team and empowering them with specific patient-centered interventions that can improve their outcomes cannot be understated. Demonstrating that a nurse navigator-led prehabilitation workshop decreased the outmigration rate is one way of showing value independent of reimbursement. In fact, other measures of nursing and navigation value include improved access to services, better adherence to cancer treatment, reduced hospital length of stay or unplanned readmissions, increased patient satisfaction, increased physical and/or functional outcomes, reduced numbers of negative metastatic workups for untreated musculoskeletal pain problems (eg, rotator cuff impingement that causes night pain), and so on. Moreover, as payers become less focused on fee-for-service models, nurses will have more opportunities to deliver clinical services.