Overview LHIN 4 10/4/2014. Diagnostic Assessment Programs for Lung & Esophageal Cancer. Improving the Patient Experience.

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1 Diagnostic Assessment Programs for Lung & Esophageal Cancer Improving the Patient Experience CSGNA 2014 DR. COLIN SCHIEMAN ASSOCIATE PROFESSOR THORACIC SURGERY MCMASTER UNIVERSITY Overview Introduction Our Region Our Team The Diagnostic Assessment Program Concept Lung DAP Esophageal DAP LHIN 4 3 1

2 CHALLENGES FOR LHIN M RESIDENTS Has highest rates of smoking, heavy drinking and obesity in the province 25% daily/occasional smokers 32% overweight 19% obese SJHH Regional Thoracic Program One of the largest in Canada 750 major thoracic surgeries per year 450 Cancer Resections 400 lung 50 esophagus 27% drink 5 or more drinks (at once) at least 1/month Brant Community Healthcare System St. Joseph s Healthcare Hamilton Haldimand War Memorial Hospital Hamilton Health Sciences (9 sites) Hotel Dieu Shaver Health & Rehabilitation Centre Joseph Brant Hospital Norfolk General Hospital West Haldimand General Hospital Brantford General Hospital Niagara Health System (6 hospitals) THORACIC PROGRAMS Thoracic Surgery (Malignant & Non-Malignant) Respirology (SJHH, NHS, Brantford) Brant Community Juravinski Cancer Health System Collaboration Centre & Niagara Health Walker Integration Family Cancer System Centre Firestone Institute for Cancer Care Ontario Respiratory Health Integrated Comprehensive Care (ICC) Pleural Space & Pulmonary Nodule Clinics Screening & Surveillance Clinics 2

3 7 Pleural Space & Pulmonary Nodule Clinics Screening & Surveillance Clinics 8 What is a Diagnostic Assessment Program (DAP)? A specialized clinic: Single point of access NURSE NAVIGATED Streamlined scheduling & coordination of tests & consultations Follows best practices & evidence Comprehensive, Timely, Compassionate Support for patients and their families through the early part of their cancer journey 9 The DAP Clinics Work! CCO has shown through various published pilots that DAP clinics have: Simplified referral process Improved cancer work-up Reduced time from referral to treatment Increased patient satisfaction 3

4 CCO CANCER JOURNEY 10 CCO CANCER JOURNEY Paste map of DAP programs from CCO DAP Map 4

5 13 A word about Lung Cancer Statistics Canada - cancer.ca 14 Statistics Canada - cancer.ca 15 5

6 Statistics Canada - cancer.ca Statistics Canada - cancer.ca 18 Need to do better 6

7 HAMILTON LDAP TEAM 19 St. Josephs Hamilton LDAP Team HAMILTON & BRANTFORD 20 ST CATHARINES TEAM 21 Niagara LDAP 7

8 22 What is the LDAP & How Does it Work? 23 Simplified Intake Process lung cancer 1 form for all locations & all physicians 24 The Patient s Experience 1. Referral sent to the LDAP 2. LDAP Nurse Navigator Phones patient 3. Meet the MD 4. Diagnostic Tests Planned 5. Review Tests & Plan Treatment All through one phone number, one nurse, one site as quickly as possible 8

9 Lung DAP: Patient Referrals Apr-10 Jun-10 Aug-10 Oct-10 Dec-10 Feb-11 Apr-11 Jun-11 Aug-11 Oct-11 Dec-11 Feb-12 Apr-12 Jun-12 Aug-12 Oct-12 Dec-12 Feb-13 Apr-13 Total Referrals SJHH NHS Brantford Linear (Total Referrals) LDAP IN LHIN4 How LDAP Works in LHIN 4: ~ 140 new LDAP referrals/month ~ 20% of all LDAP patients in Ontario 80% of patients receive a positive or suspected cancer diagnosis 27 LDAP Provincial Landscape: LHIN # LHIN Name Volume of Patients (Jan- Dec 2013) Disease Site 1 Erie St. Clair 292 Lung 2 South West 593 Lung Thoracic 3 Waterloo/Wellington 339 Lung 4 Hamilton Niagara Haldimand Brant 860 Lung 5 / 6 Mississauga Halton/Central West 313 Lung 7 Toronto Central North 175 Lung Toronto Central South 526 Lung 8 Central 691 Lung 9 Central East 737 Thoracic 10 South East 401 Lung 11 Champlain 1,252 Thoracic 12 North Simcoe Muskoka 218 Thoracic 13 North East 302 Lung 14 North West 176 Lung 9

10 28 LDAP Provincial Landscape: LHIN # LHIN Name Volume of Patients (Jan- Dec 2013) Disease Site 1 Erie St. Clair 292 Lung Lung 2 South West 593 > 1300 new patients in LHIN 4 DAP in Thoracic 3 Waterloo/Wellington 339 Lung 4 Hamilton Niagara Haldimand 2013 Brant 860 Lung 5 / 6 Mississauga Halton/Central West 313 Lung 7 Toronto Central North 175 Lung Toronto Pleural Central South space clinic = Lung 8 Central EDAP = Lung 9 Central East 737 Thoracic 10 South Nodule East clinics= Lung 11 Champlain 1,252 Thoracic 12 North Simcoe Muskoka 218 Thoracic 13 North East 302 Lung 14 North West 176 Lung CANCER SURGERIES AT ST JOSEPHS CCO Qualifying Cancer Surgeries Esophageal 47 Lung FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13 FY 2013/14* LDAP SUCCESS Success of HNHB LDAP program: Despite the huge increase in volume, 97% LDAP patients were very satisfied with their care Active management of patients at a time patient calls/day, addressed within 24 hours 10

11 STRENGTHS What are the strengths of our LDAP? Focus on the patient & their family Focus on eliminating unnecessary wait times Partnered with DI to prioritize all LDAP testing Fostered stronger relationships between respirology, thoracic surgery, oncology & cancer centers Stronger Voice at Major Oncology & Planning Meetings Develop other off-shoot programs in parallel to LDAP CHALLENGES What challenges does our LDAP face? Managing Complex Problems in Complex Health Care Systems with Limited Resources & People, Always Putting the Patients Needs First CHALLENGES What challenges does our LDAP face? Coordinating 3 different sites Distance between sites; differences between data systems and capture; different personnel Managing wait times with limited resources e.g., CT lung biopsies (3-5 wks), PET scans (1-1.5 wks), EBUS bronchoscopy (1-2 wks) Median wait time for St Joseph s (2013) 31 days Average time from referral to physician consultation (2013) 10 days 11

12 A WORD FROM LORRAINE, HAMILTON NURSE NAVIGATOR What we hear from patients is The waiting is the worst part. In Niagara, the collaboration between Respirology & the Thoracic Surgery at St. Joseph s provides Niagara s LDAP patients with timely access to the care they require close to home. We have also integrated radiation oncology into the LDAP team quite successfully in Niagara. - Tara Becevel, LDAP Nurse Navigator for Niagara Health System Leveraging The Success of the LDAP model for Esophageal Cancer: A highly morbid disease with complicated testing and workup required Noticed things were splintered & as result there often delays > 6 months in patients getting to a specialist 12

13 THE PATIENTS JOURNEY WITH ESOPHAGEAL CANCER 37 Helen is a 67-year-old retiree from Niagara Falls. She was diagnosed with esophageal cancer and is planned to undergo chemotherapy, radiation and surgery Helen s care will be provided in two different locations: Juravinski Cancer Centre (JCC) for chemotherapy and radiation therapy (71 kilometres) & St. Joseph s Healthcare Hamilton (SJHH) for surgery (74 kilometres ). THE PATIENTS JOURNEY WITH ESOPHAGEAL CANCER 38 Helen s esophageal cancer care If there are no complications, her treatment will require at least 66 visits > 9,500km of travel!!!: consultations with medical, radiation and surgical oncology for multidisciplinary plan (1 visit to JCC); radiology or ancillary service visits (e.g., PET scan, CT scan, endoscopy, echo, PICC line) (5 visits to SJHH); simulation for radiation (1 visit to JCC); daily radiation treatments (25 visits to JCC); chemotherapy (4 visits to JCC); radiation oncology (6 visits to JCC); medical oncology & dietitian (eight visits to JCC); pre-operative visit to surgeon (2 visits to SJHH); pre-op clinic (1 visit to SJHH); surgery with two-week hospitalization (12 visits by informal/family caregiver to SJHH); and post-operative surgeon visit (1 visit to SJHH). She will also require at least six months of weekly home care services coordinated by her Community Care Access Centre. HNHB LUNG DIAGNOSTIC ASSESSMENT PROGRAM Created the Esophageal Diagnostic Assessment Program: Based on success of our LDAP program Multi-disciplinary care model Nurse navigator provides diagnostic, treatment and care coordination First of it s kind in Canada From suspicion of disease until cure or death 13

14 40 EDAP COMPREHENSIVE CARE PROGRAM Goals of the EDAP Program Reduce the worry and wait contact within 48 hours Single Point of Contact Rapid Testing & Diagnosis Longitudinal Care & Support Throughout Journey (until death or cure) Improved communication with referring physicians Improve Outcomes Increase multi-disciplinary collaboration between regional sites (JCC, SJHH, NHS, and BGH) Education & Research 14

15 43 Very Different Problem than Lung Cancer Esophageal Cancer Background 5 year survival among the lowest of all cancers, < 15%, second only to pancreatic cancer BUT of those that are resectable, 5-year survival is 30-40% Estimate for LHIN 4: new patients/yr At SJHH we perform ~ 55 esophagectomies/year, the highest number of cases in ON 15

16 46 Piggybacking on the LDAP success & resources Simplified Intake esophageal cancer 47 Constructed the EDAP Clinic Multiple Stakeholder meetings Fundraising (Grants/LHIN support) Hired nurse navigator & clerical staff Advertised throughout the LHIN EDAP TEAM 48 16

17 PHYSICIANS 49 Referrals started trickling in 50 # EDAP Referrals by Region Hamilton Brantford 27 Niagara Haldimand 72 Norfolk Other

18 Proportion of symptom occurrence at presentation in EDAP EDAP Statistics after 1 year: 176 referrals (April 2013 March 14) Average referrals per week: 3.6 Average 17 days from referral to decision to treat Referral to initial contact by NN: 0.6 Day Referral to physician consult : 3 Days Referral to completion of testing: 15 Days QUESTIONS? 18