Optimizing Care for Cancer Patients: Care Coordination
In the first post in this series, we introduced our oncology patient journey research with AstraZeneca and health systems. This included qualitative and quantitative data collection to help us better understand the barriers and challenges in treating and managing patients with cancer. In this and subsequent posts, we will look at the research findings as well as tools and resources we developed and tested to help address barriers and challenges.
Let’s start with care coordination.
Care teams face many care coordination challenges and barriers. Supportive care staff, such as social workers, behavioral health providers, nurses, patient navigators and palliative care staff, are typically responsible for managing patient experience factors such as stress levels, symptoms and side effects. (1-4) Some clinics use nurse navigators to help patients on their oncology journey and to address barriers patients encounter. The nurse navigator may provide patient resources and education, referrals to specialists, emotional support or other assistance as needed. However, many clinics do not have dedicated nurse navigators; instead, medical oncologists and clinic nurses report that they are often expected to fulfill these responsibilities in addition to their routine tasks.
Oncology care coordination gaps can lead to referral delays. These gaps can include the lack of a standardized intake process for barrier assessment as well as patient-level resources for planning and education, which would accommodate different learning styles and various levels of patient health literacy. Providers also mentioned patient education gaps for biomarker testing, treatment options, genetic risk factors and palliative care. Finally, a patient may need a wide range of other services as they navigate the care continuum, including transportation and meals, that may need to be contracted and arranged.
To address these issues, we developed a Nurse Navigator Toolkit that nurse navigators, care coordinators or other care staff can use for care coordination across the patient journey.
The Nurse Navigator Toolkit includes:
- A barrier assessment checklist to assess for financial, logistical, emotional and behavioral barriers that may negatively impact the patient journey.
- A biomarker discussion guide to facilitate patient education on biomarker testing, including the importance of testing, how biomarkers tests are obtained and potential implications of positive results.
- A documentation process template to standardize receipt, upload and provider notification of third-party biomarker results.
- A patient treatment planner that enables patients to see their upcoming tests, treatments and appointments on one page.
- A palliative care discussion guide to facilitate patient education on palliative care in oncology. The guide reviews common myths and the benefits of integrating palliative care into the patient journey.
Several tools in the toolkit are in a fillable PDF format that can be edited and saved.
Feedback on the toolkit indicated that it was “comprehensive,” “useful and detailed,” “could be a good educational resource” and addressed “a high need to effectively communicate across the care continuum between multidisciplinary teams” as well as to provide support for nurse navigators in their roles. Some noted it would help remind staff of questions to ask patients and could be used as “a helpful reminder to hit on key aspects of patient daily life that could impact their care.” One nurse navigator said, "I love the patient resource guide [in the toolkit] and the way it's set up; it’s more concise, and the information is better than what we have." Others said it could help address struggles with patient portals and could be used as a training tool with new staff. Several providers and nurse navigators said the palliative care discussion guide in the toolkit addressed the importance of bringing up the topic earlier in the care journey and could help avoid confusion with hospice and end-of-life care. Many of the providers wanted to share the toolkit with co-workers and other teams.
In the next posts in this series, we will synthesize our findings on barriers and challenges related to patient presentation, additional work-up and biomarker testing. As we did in this post, we’ll also present the tools and resources we developed and tested with providers to address these areas and to help them better manage these patient populations.
Want to learn more? Contact Misty Anderson for additional information on this project and Diane Loughlin if you are interested in getting involved with future research studies.
Authors:
Misty Anderson, MBAHM, BSN, RN, LSSMBB, oversees the Improvement Science team of Premier Applied Sciences (PAS). She is responsible for building standards that support evidence-based review, qualitative analysis, research and quality methods, content management and training for new and existing customers within PAS.
Cate Polacek, MLIS, CMPP, ELS, is a Senior Medical Writer on the Applied Research team within PAS. She provides writing, editing, academic research and publication services across PAS. She writes journal articles, patient and provider education, white papers, study protocols, literature reviews and qualitative analyses for all major therapeutic areas.
Nicholas Travis, MSN, BSN, RN, FNP-C, is a Manager of Content Generation on the PAS Improvement Science team. He develops tools, resources and other clinical content to support various projects. He creates frameworks, care pathways, webinar presentations, clinical support tools, patient and provider facing materials, and other clinical content for projects.
Erika Klump, MS, is the Technical Product Director on the Data, Technology and Innovation team of PAS. She works with research teams, health care systems, engineers and informaticists to ensure PAS projects have the structured or unstructured data and technology needed for project objectives.
Erica Robichaud, PT, DPT, MHA, is the Project Owner and Director on the Improvement Science team. She is responsible for overseeing the project, ensuring the quality and timeliness of deliverables and maintaining customer services. Her collaboration with the team, sites, providers and subject matter experts is key to the successful execution and completion of the project.
Andrew Long is an Analytics Developer on the Data, Technology, and Innovation team of PAS. He works to develop data pipelines integrating structured and unstructured data. He informs and implements data validation and optimization strategy for leveraging NLP solutions and supports various other PAS data solutions.
Nancy Rios is a Research Analyst on the Data, Technology, and Innovation team. She collaborates closely with cross-functional teams including research, health care systems and technology experts. Her responsibilities extend to developing and implementing data validation procedures, leveraging natural language processing solutions for data optimization and informing data quality enhancement strategies.
References:
1. Somayaji KH, Handorf E, Meeker CR, et al. Psychosocial needs of older patients with metastatic breast cancer treated at community centers. J Geriatr Oncol. Mar 2023;14(2):101444. doi:10.1016/j.jgo.2023.101444
2. Wang Y, Feng W. Cancer-related psychosocial challenges. Gen Psychiatr. 2022;35(5):e100871. doi:10.1136/gpsych-2022-100871
3. Tack L, Schofield P, Boterberg T, Chandler R, Parris CN, Debruyne PR. Psychosocial Care after Cancer Diagnosis: Recent Advances and Challenges. Cancers (Basel). Nov 29 2022;14(23)doi:10.3390/cancers14235882
4. Breidenbach C, Kowalski C, Ansmann L, et al. Incorporating psychosocial care into routine oncological care: Insights into challenges and strategies from certified cancer centers' audit data. Psychooncology. Aug 2022;31(8):1331-1339. doi:10.1002/pon.5933