Adaptation of Survivorship Care Plans in the Age of the EMR Challenges & Practical Solutions

Transcription

1 Adaptation of Survivorship Care Plans in the Age of the EMR Challenges & Practical Solutions Elizabeth McGrath, DNP, APRN Darcy Kreis MS, RN Norris Cotton Cancer Center Dartmouth Hitchcock Medical Center Lebanon, NH

2 Objectives Describe the essential components a Survivorship Care Plan (SCP) List strategies to overcome barriers to implementation of SCPs Identify mechanisms to incorporate an SCP into the EMR

3 Norris Cotton Cancer Center NCI designated cancer center in rural New Hampshire Main campus located in Lebanon NH 14 oncology outreach sites throughout NH/VT Over 60 specialty programs Affiliated with Geisel Medical School at Dartmouth College 3 Year Hematology/Oncology fellowship program 16 Hem/Onc APRN s Lebanon campus

4 APRN Role APRN s work in collaboration with physician, see patients independently and in conjunction with the team Team includes RN clinical coordinators, patient navigators, research RN s, pharmacists, nutritionist, PT/OT, psychiatry, chaplaincy, social work, palliative care, supportive services, and administrative support Inpatient and outpatient APRN s are responsible for care of patients across the cancer continuum which includes Survivorship Care Plans (SCP s) QI project was done to standardize the process of developing SCP s and the delivery of the SCP to patients & PCP s

5 Background Institute of Medicine (2007) recommendations from: Cancer Patient to Cancer Survivor: Lost is Transition Raise awareness of cancer survivorship Provide a care plan for survivors Develop clinical practice guidelines for caring for cancer survivors Overcome healthcare system challenges Address cancer survivorship as a public health concern Address survivors employment concerns Improve access to adequate and affordable health insurance Invest in research

6 Background Survivor care plan (SCP) serves as an individualized plan of care Institute of Medicine (2007) recommended Survivorship Care Plan (SCP) include: Treatment summary Detailed plan of follow-up care Late effects American College of Surgeons Commission on Cancer (CoC) has mandated that all patients receive a SCP after completion of therapy as a condition of accreditation after 2015

7 Background Historically patients lack knowledge regarding: Follow-up care Surveillance recommendations Who is responsible for care Recurrence anxiety Long term side effects and complications

8 Background Cancer patients are faced with unique challenges Psychological Social/Financial Physical Spiritual Ferrell et al. 1995

9 Models of SCP Care Physician Led APRN Led Higher overall satisfaction Background Better education verbally and written with review of SCP Skill Set, time and clinical expertise make APRN s ideal for role Only model of care that improved QOL measures and process/cost efficiency Spears, J. et al 2017

10 Background SCP Templates American Society of Clinical Oncology- (Chemotherapy Treatment Plan & Summary LIVESTRONG (LIVESTRONG Care Plan) National Coalition for Cancer Survivorship (Journey Forward)

11 NCCC has been providing SCP s since 2007 Iterative process Background Pilot study with PCP s to test original template Made improvements based on findings Study to evaluate effectiveness with patients and PCP s Confirmed SCP are valuable to both patients and PCP s Dulko, et al. 2013

12 Background 2014 developed Survivorship Steering Committee FTE funded positions MD & APRN as co-chairs Interdisciplinary Subcommittee focus areas: Survivorship Care Plans Psych-oncology including Distress screening Prehab/rehab Neurocognitive screening Chemotherapy-induced peripheral neuropathy Communications

13 Barriers to SCP s A standardized process does not exist Does not exist in EMR Inability to incorporate existing templates into EMR LIVESTRONG ASCO guidelines Journey Forward

14 Addressing Barriers Quality improvement task force put in place Interdisciplinary membership Physician APRN s Informatics Specialist Quality Improvement Project Manager DMAIC process followed

15 Addressing Barriers Value of Quality Improvement Initiative Inherent administrative buy-in Standardized process development with outcomes measured and process refined Creates performance expectations

16 Quality Improvement

17 SCP Subcommittee SCP subcommittee meeting monthly since 10/14 Goals Standardize SCP format across all disease sites Develop work flow for completion and delivery of SCPs Mechanism to identify appropriate patients Implement comprehensive symptom assessment tool during SCP visit Adopt best practice for symptom management

18 Process Improvement Objectives All patients treated with curative intent chemo/radiation SCP completed within days after completion of therapy Created and delivered by APRN s Integrate the SCP into the EMR

19 EMR Integration Barriers to SCP s include time and cost Expectation that EMR can expedite SCP development and delivery Templates are key UNC able to decrease time to build SCP from 20 minutes to 5 minutes Zabora et al, 2014 Myer et al, 2015

20 Patients treated at NCCC with curative intent Pre- EMR Measurements

21 Measurements Initially a random chart review of 50 charts revealed only 4 (8%) had a completed SCP

22 Root Causes Lack of standard process to identify eligible patients Lack of standardized tool to document SCP Recent adoption of EMR- no placement for SCP APRN knowledge deficit regarding value of SCP visit Time involved in creating SCP No scheduling process for SCP visit

23 Steps Taken Create an SCP template following ASCO guidelines Disease groups to build specific templates Integrate SCP into EMR Begin at time of diagnosis

24 Informatics Role of Informatics Specialist/Resources IT knowledge IT resources for EMR build Support from Director of Quality and Patient Safety Embedded in department Autonomy Clinical Background

25 Steps to Developing a Survivorship Care Plan Template Pre-work, SCP template were found in letters

26 Steps to Developing a Survivorship Care Plan Template Pre-work, SCP template were found in letters

27 Steps to Developing a Survivorship Care Plan Template SCP template were found in letters but were transitioned to flowsheets, now found under problem list.

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29 SCP in EMR

30 ComplCompleted SCP

31 Steps to Developing a Survivorship Care Plan Template Edited 16 flowsheets with individual disease specialty Submit changes to IT builder on IT team Builder makes changes in test environment called TST Changes are tested by a second builder Submit changes to edh approval workgroup for review and approval Changes moved to edh with next weekly update

32 Measurements 3 months after initial roll out repeat chart audit demonstrated: Better utilization of IT support in audit 200 charts reviewed (fit criteria) Increased to 11% Continued work on EMR integration Work arounds Letters

33 Adaptation of Survivorship Care Plans in the Age of EMR's Anna Schaal MS, APRN; Darcy Kreis MS, RN; Claire Pace MS, APRN, Jennifer Snide MS; Elizabeth McGrath DNP, APRN Norris Cotton Cancer Center, Lebanon, New Hampshire 2016 Background Cancer survivors and their health care providers are faced with unique challenges following the completion of cancer therapy increased risk of both cancer and its treatment related morbidities premature mortality confusion regarding suggested surveillance and routine screening coordinating care with multiple health care providers It has been recommended by the Institute of Medicine and ASCO that patients be presented with a Survivorship Care Plan (SCP) at the completion of cancer care Methods Measure Random chart review of 50 patient charts (2015) Completed SCP s = 4 or 8% Analyze Random chart review reveals patients rarely receive SCP s Root causes include: Lack of standard process to identify eligible patients Lack of standard tool, chart placement. Difficulty with EMR Knowledge deficit regarding value of SCP visit Time involved in creating SCP and scheduling SCP visit Improve Improve Created templates incorporating ASCO guidelines related to disease specific follow up by oncology and primary care providers, including a plan for disease surveillance and education regarding health behaviors to promote wellness DMAIC Model of Process Improvement Define Who should receive a SCP? All patients treated at NCCC with chemotherapy or radiation therapy with curative intent. What is the SCP? It is a summary of their specific cancer diagnosis and treatment as well as a guide for patient s use in managing their symptoms. When is the SCP visit to take place? days after completion of therapy. Who will create and deliver the SCP visit? Nurse Practitioners at the NCCC. Goal: 70% of eligible patients receive SCP by 2016 Implemented standard EMR functionality to document Survivorship Care Plans in a central location within the medical record Standardized collection of disease specific patient level information that flows automatically to the Survivorship Care Plan Control Quarterly evaluation of number of SCP s done for qualified survivors Ongoing assessment of workflow Future Directions Study is needed to continue to assess the usefulness of the SCP EMR data extraction using doc flowsheet functionality Improve SCP dot phrase to include common symptom management References 1. Hewitt, M., Greenfield, S & Stovall, E. (2005) From cancer patient to cancer survivor: Lost in transition. Committee on cancer survivorship. Improving care and quality of life, Institute of Medicine & National Research Council. The National Academies Press. Washington, D.C. 2. McCabe, M.S, Bhata, S., Oeffinger, K.C., Reaman, G.H., Tyne,C., Wollins,D.S. (2013). American Society of Clinical Oncology Statement: Achieving high-quality cancer survivoship care. Journal of Clinical Oncology, 31 (5).

34 Repeat Measurement After 6 months 11% increased to 16% EMR integration completed with APRN training 200 chart reviews ALL NP s participated in chart reviews Data collected for root causes of incomplete SCP s

35 Root Causes Complex patients on Maintenance/hormonal therapy need to re-define curative therapy Timing for bone marrow transplant patients Local oncology follow up Providers who do not have NP collaboration, i.e. radiation

36 Next Steps Process to identify patients across all disease management groups Standardized scheduling process Increase delivery of SCP to 70% of all eligible patients by the end of 2017 Establish maintenance and updates of electronic templates Expand Survivorship care planning to include metastatic long term survivors

37 References Institute of Medicine. Cancer care for the whole patient: meeting psychosocial health needs. Washington, D.C: National Academies Press: Spears, J.A., Craft, M.C, & White, S. (2017). Outcome of cancer survivorship care provided by advance practice RNs compared to other models of care: A systemic review. Oncology Nursing Forum 44(1); Mayer, D., Taylor, K.,Gerstrel, A., Coghill,A. & Birken, S.A. (2015). Implementing survivorship care plans within an electronic medical record. TheOncologyJournal.com. Dec; Zabora, J.R., Bolte, S., Brethwaite, D., Weller,s. & Friedman,C. (2015). The challenges of the integration of cancer survivorship care plans with electronic medical records. Seminars In Oncology Nursing 31(1); Kantor, D. & Suzan, Z. Issues of Cancer Survivorship. Philadelphia, PA: Wolters Kluwer: Ferrell, B. R., Hassey-Dow K., Grant, M. (1995). Measurement of the QOL in cancer survivors. Quality of Life Research, 4; Dulko, D., Pace, C.M., Dittus, K.L., Sprague, B.L., Pollack, L.A., Hawkins, N.A., & Geller, B.M. (2013). Barriers and facilitators to implementing survivor care plans. Oncology Nursing Forum. Nov; 40(6);

38 Thank You