Most cancer care providers are familiar with the report From Cancer Patient to Cancer Survivor: Lost in Transition, released in 2005 by the Institute of Medicine (IOM). Almost a decade old now, the report detailed shortfalls in the cancer care system undermining the transition of patients from treatment to survivorship. Recommendations from the report include practical items such as providing a survivorship care plan to each patient as well as addressing system wide issues such as coordination of care across diverse communities and improved access to care.1
In September of 2013, the IOM delivered a new report, which concluded that the cancer care delivery system was in a crisis.2 The report, Delivering High Quality Cancer Care: Charting a New Course for a System in Crisis, described a system that was not patient-centered, accessible, evidence-based, or well-coordinated.2
Interesting to note is that, in the 8 years between the reports, the number of cancer survivors cited increased by 4 million people, with the 2013 report quoting 14 million survivors. So a cancer system that has not seemed to improve in 8 years is increasingly burdened with a growing population of survivors.
The health care system has undergone many changes in the last few years as politicians and decision makers try to make the system less expensive, more efficient, and able to address some of the identified needs for quality care. The Patient Protection and Affordable Care Act is the most prominent of these measures. The impact of these changes, which mainly focus on technology and reimbursement, have met with mixed results so far, as the well-publicized political battles rage on.
NEW ROLES FOR NURSES
Patient-centric care is designed to meet the needs of the patient and their family by supporting their active involvement in treatment decision-making. The introduction of nurse navigators to the mainstream of health care has impacted both the patient experience as well as care coordination.3 The role of the nurse navigator fits nicely into the IOM model for delivering quality care by providing a well-trained professional whose main focus is to guide the patient through the complexity of diagnosis and treatment. The navigator becomes the support person for the patient both emotionally and clinically. The navigator can operate outside of the usual treatment silos in cancer care, overlapping the areas of diagnosis, treatment (surgery, chemotherapy, and radiation therapy), and perhaps even survivorship. An effective navigator should be able to help eliminate problems associated with poor care coordination, duplication of care, and accessibility.
But a navigation program has to be supported at the hospital level, as it is unlikely to be owned by one of the traditional treatment silos. From this perspective, the value of a navigator has to be seen in the coordinating role they play, as navigation is not a billable service that can be seen to pay for itself in traditional fee-for-service models.
Survivorship programs suffer from this same ownership issue. Patients receive treatments from each of the treatment specialties, but none specifically take ownership for the patients when they leave the treatment phase. The primary care physician is expected to fill this role, but often they do not have the knowledge to deal with treatment-related side effects. Survivorship nurses have skills to deal with survivor issues but need support at the hospital level to provide this valuable service.
CHANGING THE REIMBURSEMENT MODEL
In the 2013 IOM report, alternate care models such as accountable care organizations (ACOs), oncology-centered medical homes, and bundled payments, which reimburse for medical care based on quality measures rather than fee-for-service, are recommended.2 These models can be considered supportive of the roles of navigators and survivorship nurses as they shift the payment system from fees for medical procedures to fees for overall patient outcomes and quality care. The supportive roles of navigators and survivorship nurses mesh with these care models, as many of the services they provide are not billable procedures but add to the quality of care the patient receives.
The Centers for Medicare and Medicaid Services (CMS) is supporting this change in reimbursement by providing options for those providers willing to switch their approach to care for Medicare patients.4 Although some providers worked with CMS’ Pioneer program to trial the ACO model, not all of them continued with the program. Of the 32 Pioneer ACO participants, nine left the program after the first year. On average, the Pioneers were able to slow cost increases, but only 13 participants were able to lower costs sufficiently to generate savings to CMS for which they would then be eligible to share. Two Pioneers actually spent more money than expected and were required to reimburse CMS approximately $4 million. Views on the success of the Pioneer program are mixed and often politically charged.5-9
Regardless of the perceived success or failure of ACOs, getting every provider to switch to one of these new models of reimbursement is not likely to happen. Whether it be simple inertia or fear of losing money—as some Pioneer ACOs did—some care providers will not change.
TECHNOLOGY: A SOLUTION, A BAND-AID, OR A PROBLEM?
Technology is often touted as the solution to any given problem. Health care is no different with the push by CMS for adoption of electronic health record (EHR) technology through the Meaningful Use programs.10 CMS lists the benefits of the Meaningful Use programs as improving quality, engaging patients, and improving care coordination.11
The barriers of cost and operational integration as well as skepticism about the clinical value have been cited as reasons for the slow adoption of EHR technology.12 However, EHR implementation is occurring at double the rate of 2009 through the CMS’ Meaningful Use programs.13 As this adoption process is still in its early stages, several technology issues still confound the goals of the 2013 IOM report. Interoperability and exchange of information between EHR systems are significant issues. This is a particular challenge during transitions of care where the patient moves from one provider or institution to another.13 Information has to be transferred between providers, and solutions for this are rudimentary.
The survivorship care plan remains an important part of delivering patient-centered care. The provision of a care plan for a patient who has finished cancer treatment demonstrates the challenges that still encumber providing patient centered care. The survivorship care plan generally contains the summary of any treatment the patient has received as well as other important information such as
- Diagnosis and staging, as well as biomarkers and specific tissue information;
- Recommended follow-up activities and surveillance;
- Education on short-term and long-term side effects, as well as symptoms of recurrence; and
- A plan for addressing a patient’s psychosocial needs.
However, getting all this information into one package to deliver to the patient remains a significant challenge for oncology nurses. The American College of Surgeons Commission on Cancer (CoC) surveyed 1,390 of its member programs in the summer of 2013. Only 40% of the CoC programs felt that they were able to meet Continuum of Care Service Standard 3.3, which requires the institution to deliver a care summary and follow-up plan for each patient. Of the three Continuum of Care standards, the other two being patient navigation process and psychosocial distress screening, this standard was indicated as the hardest to meet due to the time required to prepare a meaningful summary and lack of reimbursement for the task.14
The time consuming nature of creating the care plan is surprising given that most of this information exists within the array of electronic medical records that health care providers use. The trick, obviously, is in the ability to link multiple systems and pull the pertinent information into one package in a format that is useful to the patient. An oncology nurse may be doing most of this task today, accessing multiple EHRs, reading and summarizing information from unstructured text fields, and arranging it in a Word document for the patient. Doing a good job of this is time consuming, inefficient, and nonbillable.
Technical challenges in information exchange may improve through the Meaningful Use programs. However, implementing Interface solutions between the silos of information residing in hospital EHRs may entail some cost, which cost-conscious hospitals may not be willing to pay. Technology may eventually reduce the time needed to create a survivorship care plan, but the task is still just one of many oncology nurses complete to fully support a survivorship patient. Dedicated IT tools are needed to help the oncology nurse work efficiently.
CURRENTLY AVAILABLE SOLUTIONS
Improvements in the areas of navigation and survivorship, with the assistance of technology, may achieve the goals of the IOM without creating a political minefield. An argument can be made that even in today’s health care environment, there is sufficient business incentive to justify the cost of navigation and survivorship programs.
By applying current CPT codes to survivorship follow-up guidelines from the National Comprehensive Cancer Network (NCCN), a business case can be made that actively managing patients, using dedicated care coordination software can be a profitable addition to a health care network. Efficiencies gained through better coordination of care across a multidisciplinary continuum within a hospital network would enhance the diagnostic and treatment capacity of the facility. The cost of operating the survivorship program for a typical mix of patients (30% breast, 15% lung, 20% prostate, and the remainder a mix of other diseases) in a facility seeing 1,500 patients per year with modest referral growth (2%) can be recovered with this type of efficiency. The basis for this business case comes from several avenues: patient retention, operational efficiency, and efficient resource allocation.
Patient retention Active navigation and survivorship programs engage patients and provide for a seamless transition into the services offered by the hospital. From a strictly business aspect, navigators will be referring patients to services within their own hospital network. Meaningful encounters with the patient could also encourage the patient to stay within the hospital network, as the experience with the navigator can build brand loyalty for hospital services. In addition, barriers to care, such as financial and psychosocial needs that may influence patient attendance at medical appointments, can be addressed by these programs.
Operational efficiency Just like physicians with paper charts, navigator and survivorship tools of the past have included paper calendars and Excel spreadsheets. True productivity gains can be made using electronic tools to manage patient schedules, coordinate tasks, and gather patient health information. In addition, evaluation of activity using data captured within an electronic system can lead to incremental improvement of operations.
Efficient resource allocation With dedicated navigation and survivorship programs, nurses and nurse practitioners can carry out the bulk of routine patient interactions, involving the physician as needed. Physicians are able to focus on tasks such as new patient consults and planning treatment delivery. The use of these physician extenders can help maintain a high level of care as the predicted shortage of oncologists becomes evident in the coming years.15
While able to make the case for navigation and survivorship on the business side, the corollary, happily, is improved patient care. Engaging the patient with a navigator program has the benefit of providing guidance at a challenging time for most patients. The period of diagnosis and transition to treatment can be a distressing time. Having a nurse navigator to assist the patient through these transitions is recognized by the American College of Surgeons in their accreditation standards and has been shown to increase patient satisfaction with care.3,17
Survivorship programs also provide emotional support to patients. Many patients experience difficulty as they leave the treatment care team they have had for many months. The survivorship nurse is able to provide some context to the follow-up tasks needed as well as be a connection to the oncology team during the transition period to life after cancer.
TECHNOLOGY AS A CHANGE AGENT
Nurse navigators and survivorship nurses have valuable roles in care coordination. Like any care provider, they need tools that allow them to effectively manage their patients. Traditional EHRs often do not support the workflow and documentation needs of specialty support roles such as nurse navigators and survivorship nurses. These providers coordinate and document their daily activities in generic systems that may not be efficient or support their activities. Manual solutions are not an option.
No doubt, robust technology is needed. Coordinating care for patients in a growing survivorship program will require tools that track follow-up care tasks, help clinicians manage their time, and engage patients in their own care. Technology companies are doing their best to create tools to help care providers. Information exchange standards such as Health Level 7 (HL7) and interconnectivity between EHR systems should become more commonplace and widely available. Stage 2 of Meaningful Use pushes organizations to exchange information between systems and use the information that has been exchanged.
While the focus here has been on navigation and survivorship in cancer care, the business case easily models out for managing other chronic conditions within a hospital network. Cardiac care, hypertension, and diabetes are all examples of chronic diseases that could be served by navigation and coordinated follow-up, or survivorship. Electronic tools that coordinate care and summarize treatment information from various treatment silos can be used to manage follow-up tasks necessary for patients with more than one chronic disease. CMS seems to partially recognize the value in this as they have begun providing reimbursement for providers who manage the care for patients with two or more chronic conditions.
SURVIVORSHIP CARE BUNDLED INTO ONE EFFICIENT WORKFLOW
Karen is a survivorship nurse. The facility where she works provides her with a dedicated software tool, Equicare CS, to help her prepare patients for life after cancer treatment. The tool allows Karen to manage her patient cases as well as meet each patient’s individualized needs. Using Equicare CS, Karen is able to
- Check a schedule of patients that she is actively managing in her Survivorship program
- Provide an automatically generated comprehensive treatment summary for each patient
- Assign a nationally recognized schedule of follow-up tasks appropriate for that patient
- Provide education materials on the short- and long-term side effects of cancer treatment
- Assign quality of life questionnaires that will evaluate patient condition now and in the future Set up automatic reminders for the patient for all appointments and follow-up tasks.
As all these tasks can be performed with one comprehensive technology tool, Karen can do this in minutes, rather than hours.
The IOM has provided insight into the difficulties in providing efficient and coordinated care in cancer treatment delivery. Although CMS has tinkered with the reimbursement model in an attempt to promote change, their actions may not be sufficient to initiate widespread acceptance. A different approach may be to see the value in coordinated care within the existing structure of the health care environment. Nurse navigators and survivorship nurses, using electronic tools, can manage the care of patients outside of the traditional treatment silos. From a business perspective, these care providers can generate sufficient activity within the hospital network to offset expenses, and ultimately generate revenue. Electronic tools that exchange information and make coordinating care more efficient are necessary to support theses care providers in delivering meaningful services to the ever-increasing number of cancer survivors.
Mike Darud is senior clinical analyst for Equicare Health, an industry leader in providing care coordination software for survivorship and navigation, based in Vancouver, British Columbia, Canada.
1. Hewitt M, Greenfield S, Stovall E, eds. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006.
2. Levit LA, Balogh EP, Nass SJ, Ganz PA, eds. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Washington, DC: The National Academies Press; 2013.
3. Wagner EH, Ludman EJ, Aiello Bowles EJ, et al. Nurse navigators in early cancer care: a randomized, controlled trial. J Clin Oncol. 2014;32(1):12-18.
4. The Affordable Care Act: Helping providers help patients. A menu of options for improving care. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/Downloads/ACO-Menu-Of-Options.pdf. Accessed October 24, 2014.
5. Patel K, Lieberman S. Taking stock of initial year one results for Pioneer ACOs. HealthAffairs Blog Web site. http://healthaffairs.org/blog/2013/07/25/taking-stock-of-initial-year-one-results-for-pioneer-acos/. Published July 25, 2013. Accessed October 24, 2014.
6. Press release: Pioneer Accountable Care Organizations succeed in improving care, lowering costs [press release]. CMS.gov Web site. http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html. July 16, 2013. Accessed October 24, 2014.
7. Capeless M. Evaluating the first-year development of Pioneer ACO Model. EHR Intelligence Web site. http://ehrintelligence.com/2013/08/08/evaluating-the-first-year-development-of-pioneer-aco-model/. Date August 8, 2013. Accessed October 24, 2014.
8. Bunis D. Pioneer Accountable Care Organization first-year results include savings and losses. The Commonwealth Fund. http://www.commonwealthfund.org/publications/newsletters/washington-health-policy-in-review/2013/jul/july-22-2013/pioneer-aco-first-year-results. Date July 16, 2013. Accessed October 24, 2014.
9. Goldsmith J. Pioneer ACO’s disappointing first year. The Health Care Blog Web site. http://thehealthcareblog.com/blog/2013/08/16/pioneer-acos-disappointing-first-year/. Published August 16, 2013. Accessed October 24, 2014.
10. An introduction to the Medicaid EHR Incentive Program for eligible professionals. Washington, DC: Center for Medicare and Medicaid Services; 2014. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/EHR_Medicaid_Guide_Remediated_2012.pdf. Accessed October 24, 2014.
11. Meaningful Use definition and objectives. HealthIT.gov Web site. http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives. Accessed October 24, 2014.
12. Greenspun H, Coughlin S, Stanley EL. Physician Adoption of Health Information Technology: Implications for medical practice leaders and business partners. Washington, DC: Deloitte Center for Health Solutions; 2013. http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/Health%20Care%20Provider/us_dchs_2013PhysicianSurveyHIT_051313%20%282%29.pdf. Accessed October 24, 2014.
13. The Office of the National Coordinator for Health Information Technology. Update on the Adoption of Health Information Technology and Related Efforts to Facilitate the Electronic Use and Exchange of Health Information: A Report to Congress. Washington, DC: Office of the National Coordinator for Health Information Technology (ONC); June 2013. http://www.healthit.gov/sites/default/files/rtc_adoption_of_healthit_and_relatedefforts.pdf. Accessed October 24, 2014.
14. Rosenthal ET. Deadline for survivorship care plan compliance being rethought. Oncology Times. 2014;36(13):1,14-16. http://journals.lww.com/oncology-times/Fulltext/2014/07100/Deadline_for_Survivorship_Care_Plan_Compliance.4.aspx. Accessed October 24, 2014.
15. Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Onc Prac. 2014;10(1):39-45.
16. American College of Surgeons. Cancer Program Standards 2012 Version 1.2.1: Ensuring Patient-Centered Care. Chicago, IL: American College of Surgeons; 2014.
17. Lee T, Ko I, Lee I, et al. Effects of nurse navigators on health outcomes of cancer patients. Cancer Nurs. 2011;34(5):376-384.