How can we facilitate cross-boundary working in Greater Manchester?

Transcription

1 How can we facilitate cross-boundary working in Greater Manchester? Emma Halkyard Nurse Clinician

2 Cross boundary working: where are we now? Our patients are complex Our pathways are complex Our treatments are complex Reactive rather than proactive service

3 Complex patients Brian, 76yrs, former smoker (20 pack yrs) Oes & lung ca 2007 surgery chemo 2012 radiotherapy Gefitinib (9m) 2017 Osimertinib (12m) Claire, 28yrs, never smoker Adeno ca lung brain, bone, liver, adrenals, spleen, ROS1 +ve 2016 chemo 2017 Entrectinib? (phase 2, 90% response rate)

4 Complex patients How to best identify our patients needs Goals of Care, HNA, Advanced Care Planning Survival/survivorship How to recognise end of life phase/when to involve specialist palliative care

5 Complex pathways Do we know what these look like? Varies by Sector Boundaries between tertiary care and secondary care, tertiary care and primary care

6 Patient pathway tertiary lung cancer referrals Hospital to hospital referral to dedicated chest clinic Investigations MDT discussion As for XX patients (see other chart) MDT discussion Direct referral for EBUS Referral back to local hospital Referral to community services Referral back to local hospital Chemotherapy Direct referral to oncology clinics Follow up at Christie Radiotherapy Follow up UHSM Direct referral to surgical clinics Curative surgery Palliative surgery OPA at local hospital OPA XX + oncology Chemotherapy Follow up at local hospital Follow up clinic Direct admission to wards XX Urgent chemotherapy usually for SCLC Assessment Chemotherapy Best supportive care Follow up at XX Referral to community services XX Diagnostic procedures Airway management Remain at XX Palliative procedures

7 GP referral (2 week wait), other hospital physician referral Follow up in outpatient clinic, discharged to community care, reassessment for 2 nd, 3 rd or 4 th line treatment Patient pathway tertiary lung cancer referrals Hospital to hospital referral to dedicated chest clinic Direct referral for EBUS Dedicated lung cancer chest clinic Direct referral to oncology Other chest clinics clinics Investigations MDT discussion Patient pathway lung cancer patients MDT discussion Referral back to local hospital Chemotherapy Radiotherapy Palliative chemotherapy Referral to community services Concurrent chemotherapy/radiotherapy Referral back to local hospital Palliative Follow up at Christie radiotherapy Follow up UHSM As for XX patients (see other chart) Radical radiotherapy Direct referral to surgical clinics Curative surgery CT scan Palliative surgery Biopsy OPA at local hospital MDT decision OPA XX + oncology OPA Follow up at local hospital Oral targeted therapy Chemotherapy Follow up clinic Emergency admissions Direct admission to wards Ward direct admissions Referrals from other acute wards (usually admitted for unrelated condition XX XX Diagnostic procedures Airway management Palliative procedures Urgent chemotherapy usually for SCLC Assessment Chemotherapy Best supportive care Follow up at XX Surgery +/- adjuvant chemotherapy Referral to community services Remain at XX Best supportive care Points on pathway when patients would ideally be referred to lung CNS The Lung Cancer Nurse Specialists are available to support patients at any point during the patient pathway

8 Complex treatments More treatment options New and emerging therapies Difficult to determine duration of treatment at the outset When to stop treatment?

9 Defining (and structuring) the specialist nurse role Exciting opportunity in the specialist lung nurse team here at The Christie to make a real difference for our patients. Contribute to the achievement of the Greater Manchester Cancer Pathway outcomes

10 How can we improve patient care across boundaries? Shared Mental Models (D Ambruoso, 2016) Understanding the patient s Goals of Care Explicit roles and shared accountability - defining who/what/where the Key Worker is Early integration with specialist palliative care (Temel, 2010) D Ambruosos, S.F. (2016) Use of a Shared Mental Model by a Team Composed of Oncology, Palliative Care and Supportive Care Clinicians to Facilitate Shared Decision Making in a Patient with Advanced Cancer. Journal of Oncology Practice. Temel, J. (2010) Early Palliative Care for Patients with Metastatic Non-Small Cell Lung Cancer. New England Journal of Medicine

11 The vision in the lung cancer nurse team at The Christie proactive care Hear from our patients where the gaps in care exist CNS working by Sector Shared and agreed key worker roles Use of HNA across boundaries Regular and structured communication with colleagues in secondary care Regular and structured communication with colleagues in Primary care -?

12 The vision in the lung cancer nurse team at The Christie Nurse-led services: proactive care Concurrent chemoradiotherapy Oral therapies Immune therapies Phone FU on chemo review Measuring impact patient experience, avoiding admissions, reduced LOS, treatment related mortality to demonstrate value

13 Just the beginning