Gastrointestinal Multidisciplinary Cancer (GI MDC) Navigation May 3, 2012

Transcription

1 Gastrointestinal Multidisciplinary Cancer (GI MDC) Navigation May 3, 2012 Coralyn Martinez MSN, RN, OCN GI Nurse Navigator The Lacks Cancer Center Saint Mary s Health Care Grand Rapids, MI

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3 History of Navigation you can t know where you are going, unless you know where you came from those who are unaware of history are destined to repeat it - George Santayana

4 DRG s Utilization Management Nurses Utilization Review Nurses Oncology Nurse Navigators Case Management Patient Navigation

5 1999 IOM Report Ensuring Quality Cancer Care IOM report noted: For many Americans with cancer, there is a wide gulf between what would be construed as the ideal and the reality of their experience with cancer care

6 1999 IOM Report Ensuring Quality Cancer Care IOM defined Quality as the degree to which health services for individuals and populations increase the desired likelihood of desired health outcomes and are consistent with current professional knowledge

7 2001 Institute Medicine Crossing the Quality Chaism : 6 Aims High Quality Care Timely (avoiding unnecessary delays) Efficient (avoiding or reducing unnecessary, or minimally beneficial studies) Patient-centered Effective (based best evidence) Safe (from avoidable errors) Equitable (regardless socioeconomic characteristics)

8 Future of Navigation American College of Surgeons Commission on Cancer - Standard 3.1 Patient Navigation Focuses on health disparities and is driven by needs assessment of the community - Standard Survivorship care plans Comprehensive care summary and follow up presented to patients at completion of therapy Sein, E. (2011). Patient Navigation Becomes New Standard for Cancer Program Accreditation. Academy of Oncology Nurse Navigators. Retrieved from

9 What is a navigator? Provider of services Barrier eliminator NCI CRHCD definition: to support and guide persons with abnormal cancer screening or a new cancer diagnosis in accessing the cancer care system, overcoming barriers; and facilitating timely, quality care provided in a culturally sensitive manner. Dohan, D. & Schrag, D. (2005) Using Navigators to improve care of underserved patients, Cancer, 104 (4), Freund K. M., et al. (2008). National Cancer Institute Patient Navigation Research Program, Cancer, 113(12),

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12 Navigation Types Outreach Diagnostic Treatment Survivorship Patient versus nurse All in one Outpatient versus inpatient

13 Poll the Audience What type of navigator are you? - Nurse - Social Worker - Lay Person - Other What is the primary setting in which you work? - Hospital - Clinic - Health Department - Other Do you navigate additional cancer types?

14 Harold Freeman Model Freeman, H.P. (2012) Harold P. Freeman patient Navigation program/model, patient Navigation:

15 Billings Clinic Patient Navigation Model Blaseg, K. (N.D.) Patient navigation at Billings Clinic and NCO community Cancer Centers Program (NCCCP) Pilot Site. AJCCC s Cancer Care Patient Navigation: A call to action:

16 One Size fits all???

17 Goals of Navigation Identification and reduction of potential barriers to healthcare Enhanced quality of care Timeliness of services Ensure the best cancer care experience through coordinated services

18 Cancer Care Diagnosis Staging Clinical Evaluation Treatment Surveillance Survivorship

19 Breast Cancer Care Mammogram Notification Appointment Arranged Patient Evaluated Mammogram Notification Appointment Patient Evaluated Arranged

20 Cancer Incidence by Primary Site, Michigan Residents, Number of Cases Prostate Lung Breast Colorectal NH Lymp Melanoma Kidney Uterine Source: Michigan Resident Cancer Incidence File. Includes cases diagnosed in and processed by the Michigan Department of Community Health, Division for Vital Records and Health Statistics by December 29, 2010.

21 Cancer Incidence by Primary Site, Michigan Residents, Number of Cases Prostate Lung Breast GI Bladder NH Lymph Melanoma Kidney Uterine Source: Michigan Resident Cancer Incidence File. Includes cases diagnosed in and processed by the Michigan Department of Community Health, Division for Vital Records and Health Statistics by December 29, 2010.

22 Esophageal Cancer Care Patient Presents to ER with Weight Loss/Dysphagia UGI shows mass Primary Care Notified EGD Arranged with GI Doc Distal Mass Identified Biopsy performed Referral for EUS PET Scan Surgical Evaluation Medical Oncology Evaluation EUS performed Demonstrates T3, Node (+) Abd CT ordered Radiation Oncology Appointment Neo Adjuvant Chemorads Initiated 2 Days 7 Days 14 Days 21 Days 28 Days 35 Days 42 Days

23 NCCN 2009 Esophageal.jpg

24 Value Based Healthcare Every step in the sequential health care process benefits from information exchange and coordination with other providers. In practice, however, this is cumbersome, time-consuming, and often left to the busy doctors, and often fails to occur. Michael Porter, Harvard Business School Annals Surgery 2008

25 The Lacks Cancer Center Add picture here

26 The Lacks Cancer Center NCCCP Site West Michigan s only dedicated Cancer Center Community Teaching Hospital Member of Trinity Health Focus on minimally invasive surgery Patient Centered Model of Care Multidisciplinary clinics available for all solid tumors

27 Lacks Cancer Center GI Program Dedicated GI Cancer Nurse navigator - Specific Training in GI Cancer - Oncology Certified Prospective, Weekly GI Cancer Treatment Planning Conference Multidisciplinary, Same Day, GI Cancer Clinic - Surgical Oncology - Radiation Oncology - Medical Oncology - Cancer Resource Specialists - Oncology Nutritionist - Palliative Care Program of OUTCOME assessment and Measurement - Dedicated GI database - Dedicated program analyst Steering Committee with continuous feedback of Outcomes and Program assessment

28 5 Major Program Outcome Measures Timeliness - Rapid Contact with patient to identify needs, worries, and completed testing - Time measures for staging completion, Time to clinical evaluation, Time to TREATMENT initiation Patient Centered - Same Day Clinics where multiple physicians see patients in a single day - Coordinated diagnostic studies for patients, often in conjunction with clinic visit - Reduce patient time Efficient - Avoid unnecessary Testing - Avoid non-essential Biopsies Effectiveness - Appropriate Staging consistent with National Guidelines - Appropriate Stage specific cancer care - High Quality cancer care, evidence-based - BENCHMARKED Clinical Outcomes against National published standards Equitable - Fair and equal care for all patients

29 Multi-Disciplinary Team Approach Survivor Network Radiology Social Services Pathology Medical Oncology Palliative Care and Integrative Medicine Clinical Research Radiation Oncology Nurse Navigator Surgical Oncology Nutrition Services Familial Cancer Program Specialty Physicians Financial Counseling Prevention Program Cancer Education

30 GI Disease Location GI MDC Program to Date Percent of Patients Colorectal Esophageal/ Liver Pancreatic Gastric

31 Diagnoses Type Percent of Patients New Cancer Dx Cancer Recurrence Benign

32 Inpatient vs. Outpatient Referrals % Percent % % % Inpatient Outpatient

33 Role of GI Nurse Navigator Goal = Timeliness of services - Patient contact < 2 days - Organization and coordination of timely diagnostic studies < 6 days - Coordination of multidisciplinary appointment < 10 days - Coordination of treatment initiation < 25 days

34 Average Business Days Until Contacted by Nurse Navigator 2 Days

35 Average Business Days Until Cancer Staging Completion Business Days

36 Average Calendar Days Until Patient is Seen in GI MDC Clinic 10 Days

37 Patients Seen in Clinic Within 10 Calendar Days Percent Q Q Q Q

38 Role of GI Nurse Navigator Goal = Ensure the best cancer care experience through coordinated services/ Patient Centered - Shared and informed decision making - Single contact person through cancer journey - Decreased patient anxiety/ improved quality of life - Increased patient satisfaction

39 Role of GI Nurse Navigator Goal = Efficient and Effective quality care - Ensures that diagnostic studies are in concordance with NCCN guidelines - Works directly with physician lead to review diagnostic studies, clinical history and course of treatment. - Coordinates multidisciplinary evaluation and presentation at tumor board

40 Staging Compliance with NCCN Staging Guidelines Percentage % 97%

41 Role of GI Nurse Navigator Goal: Equitable care/ Identification and reduction of potential barriers to healthcare - Comprehensive health assessment - Collaboration with multidisciplinary team members - Education - Continuous patient monitoring throughout cancer journey - Enhanced communication with patient and providers

42 Referrals

43 Number of Invasive Cancer Cases for Select Primary Sites, Michigan Residents, Number of Cases Esophagus Stomach Pancreas Liver & Interhepatic Bile Ducts Gallbladder and Biliary Small Intestine Colon and Rectum Anus Anal Canal Anorectum Source: Michigan Resident Cancer Incidence File. Includes cases diagnosed in and processed by the Michigan Department of Community Health, Division for Vital Records and Health Statistics by December 29, 2010.

44 SMHC and GRG efforts to improve CRC screening Education and awareness - CRC pamphlets - CRC Banners from CDC and Marketing - Loop video from local physicians

45 CRC banners from CDC

46 Transportation Navigation: Improving Colonoscopy Completion Rates The Lacks Cancer Center and Grand River Gastroenterology Main barrier to completion = transportation 30% Cancelations in 2010 due to lack of transportation Goal was to improve transportation rates by offering transportation as well as a responsible adults.

47 Methods of transportation Navigation Life EMS partnered with SMHC and GRG to provided discounted transportation. Direct billing was established to eliminate the patient being involved. Location Urban Suburban Rural Super Rural Roundtrip Cost $48.00 $56.00 $76.00 $42.00 plus $2.00/mile for each mile outside Kent County

48 Number of Transports by Month # of Transports May June July August September October November December Month

49 110 round trips provided, Average cost per trip = $71.16 Cost per Roundtrip Transport $ $ $ $ Cost $ $ $ $50.00 $ Transport

50 Colonoscopy Cancellations Due to Lack of Transportation # of Colonoscopy Cancellations Year Decrease of 54%

51 Return on Investment Cost Patients Total Percent Colonoscopy $ $176, % Transportation $ $ % Potential Cancellation Avoidance Savings by Providing Free Transportation $168, %

52 Breakout Session What type of Navigator are you? What types of GI cancers do you navigator? What are the outcomes or your needs assessment? Feasible strategies to address barriers identified? Who makes up your GI team? List out Key stakeholders. What are the goals or objectives of your program? What is your case load? What defines your case load? How do you document? (EMR/Navigation Software/ Shadow chart) How are you measuring your accomplishments? Do you measure the quality and outcomes of the care delivered? What are your favorite resources for patients/ yourself? Keys to success/ Lessons learned?

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