GATRA/GCCR Fall Conference 14 16, /13/2012. Integration of the Rapid Quality Reporting. System (RQRS) and Patient Navigation

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1 Reporting System (RQRS) Northside Hospital Cancer Institute GATRA and GCCR 2012 Annual Conference Amy Waits, BS, CTR Northside Hospital: Atlanta, Georgia National Cancer Institute Community Cancer Centers Program (NCCCP) Site Comprehensive Community Hospital Cancer Program (CoC) 3,419 analytic cancer cases in 2011 Facilities & Services: Radiation Therapy Inpatient Oncology Units Medical Oncology GYN Oncology BMT / Leukemia Infusion Centers Hereditary Cancer Program Oncology Data Center; Central Research Office; Navigation; Community Outreach; Quality Improvement Specialty Areas: Women s Cancer; BMT/Leukemia Reporting System American Cancer Society (ACS) Grant Funded Study: Reducing Breast Cancer Disparities through a Multi level Intervention Utilizing the Rapid Quality Reporting System (RQRS) i Partnership between Northside Hospital and the Winship Cancer Institute of Emory University Grant Funding Period: May 1, 2011 May 1,

2 Collaboration Between NCCCP Site and NCI Designated Cancer Center Northside Hospital Cancer Institute (NCCCP) Emory University Winship Cancer Institute (NCI Designated Center) Established RQRS (beta Experienced Investigators test site, dedicated staff) Grant Development Navigation Program Study Design Project Coordination Data Analysis Access to High Volume of Breast Cancer Patients (>1200 per year) Northside Hospital Cancer Institute Project Team Colleen Austin, MD, Site Principal Investigator Patti Owen, MN, RN Co Investigator Margaret Currens, RN, BS, Project Manager Mildred Jones, CTR, Oncology Data Center Coordinator Amy Waits, CTR, RQRS Coordinator Michelle Yeomans, RN, Oncology Patient Navigator Kathleen Gamblin, RN, Patient Navigation Coordinator Emory University Winship Cancer Institute Joseph Lipscomb, PhD, Co Investigator Theresa Gillespie, PhD, MA, RN, Co Principal Investigator Study Objectives 1)Achieve 95% compliance in all three RQRS breast cancer measures Radiation therapy within 1 year (365 days) of diagnosis for women under 70 receiving breast conserving surgery Combination chemotherapy within 4 months (120 days) of diagnosis for women under 70 with hajcc T1cN0M0, or Stage II or IIIhormone receptor negative breast cancer. Tamoxifen or third generation aromatase inhibitor within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer. 2)Evaluate feasibility of implementing RQRS/Navigation model in other settings 3)Evaluate provider and staff satisfaction 2

3 Applicable ACoS 2012 Standards Commission on Cancer and NAPBC CoC STANDARD 4.4 Annually, performance levels are met for each of the specified accountability measures as defined by the Commission on Cancer. CoC STANDARD 4.5 Annually, performance levels are met for each of the specified quality improvement measures as defined by the Commission on Cancer. NAPBC Standard 2.13 Breast cancer quality measures endorsed by the National Quality Forum (NQF) for medical oncology are utilized. NAPBC Standard 6.2 Annual performance rates are reported for each of the measures identified by the NAPBC, and performance is evaluated annually by the Breast Program Leadership. Data for CP3R measures (which are reported to Cancer Committee) have been collected since 2004, and RQRS beta site data have been collected since NCDB Reporting CP 3 R and RQRS Measure: Alert Color Based on the # of Days until Expected Administration of non Surgical Therapy: White Yellow Orange Red Radiation therapy is administered within 1 year (365 days) of diagnosis for women under age 70 receiving breast conserving surgery for breast cancer Combination chemotherapy is considered or administered within 4 months (120 days) of diagnosis for women under age 70 with AJCC T1cN0M0, or Stage II or III hormone receptor negative breast cancer. Tamoxifen or third generation aromatase inhibitor is considered or administered within 1 year (365 days) of diagnosis for women with AJCC T1cN0M0, or Stage II or III hormone receptor positive breast cancer. 3

4 Registry Receives RQRS Alerts & Reviews for Accuracy Non Concordant and at risk Cases Referred to Navigator Monthly Registry Resubmits RQRS Data Monthly Navigator Communicates with MD Offices and patients to Address Barriers to Treatment Navigator Relays Treatment Data to Registry Registry Receives RQRS Alerts & Reviews for Accuracy Established tickler file system to anticipate upcoming treatment Initiated use of encrypted notes on individual case files Traditional Sources of Treatment Information Electronic Medical Record Other Area Cancer Registries Physician Practice portals by agreement MD Offices RQRS Registrar Free standing RT centers 4

5 Referring cases to Navigator: 1. Creation of Data Dictionary 2. Use of Spreadsheet 3. Referral Forms RQRS Reasons for Referral to Navigator: 510 No treatment information available after research by Registry 520 Patient seeing an oncologist, but documentation unavailable re: recommendation of tx 530 Treatment has been recommended, but not on target to be delivered in timely manner 535 Prescription given for hormonal therapy, but follow up appointment > 365 days from dx. 540 Patient did not return to follow up appointments after treatment recommendation 550 Financial concerns stated in documentation 560 Psychosocial issues stated in documentation 570 Patient compliance with treatment inconsistent 580 Patient refuses radiation therapy, consult not documented. 590 Patient lost to Registry follow up cannot locate patient Additional Cases Referred to Navigator: Certain non-concordant cases At-risk patients: Uninsured Language Barriers Non-compliant Patients Patients identified early in continuum of care: Mastectomy who will not receive chemotherapy but need hormonal therapy Lumpectomy who have partial breast irradiation and need hormonal therapy Navigator Communicates with MD Offices and patients to Address Barriersto Treatment Reason for Not Receiving Treatment: Alternative therapies Side effects Finances Transportation Cultural/religious practices Language Barrier Navigator Communications: Phone call to pt 2 attempts Certified letter mailed Physician notified phone or Phone call to physician office to obtain info Review pt chart at physician office F/U phone call to pt Case referred back to ODC 5

6 Outcomes and Impact of Registry and Navigation Interventions Navigation Intervention Code: Introduced pt to navigation services Educated pt on follow up care Referral to site specific navigator Referral to disparities/acs navigator Referral to Cancer Support Community Facilitated pt appointment Reason Case is Non Concordant in RQRS: Treatment not offered / delivered Treatment started late Reason unspecified Due to wound healing delays or medical complications Completion of other treatment Patient refused radiation therapy Radiation consult obtained, but radiation therapy contraindicated Hormonal tx not recommended due to triple negative status via molecular studies Unable to contact patient; no treatment information obtained Reporting System Navigation Case Studies: Non compliance with prescribed medication Patient was given a script for Tamoxifen, but was afraid to take it because still smoking & had not addressed with MD. Guided back to MD and smoking cessation program. Financial issues A patient needed hormonal therapy but had not started due to cost of the co pay. Case referred to Disparities Navigator. Hormone Therapy needed Contact with physician office revealed that patient should have been prescribed HT but had not. Non compliance with follow up / surveillance Patient missed 6 month follow up with physician and also 6 month mammogram. Through contact w/ MD office, assisted in scheduling follow up appointment. Patient compliant with treatment, but in need of Cancer Support Community services due to recent loss of spouse. Reporting System Navigation Case Studies (continued): Additional Patient Education Needed*: 1. Patient stated she was told not to take any more hormone pills. 2. Pt stated she had several friends on HTX for breast cancer and they have all kinds of side effects. 3. Patient stated she was about to be in menopause and won t have to worry about having estrogen any more. *NN frequently explained the role of hormonal blockade in reducing breast cancer recurrence risk as well as the importance of routine surveillance. 6

7 Reporting System Navigation Findings: Successful contact with patients assisted with search for treating physician names, and in turn, documentation regarding treatment. Peer to peer contact with nurses at the physician offices facilitated 1. Efficient collection of data 2. Education to the office staff of the availability of NSH NN services Challenges 1. Unable to contact some patients. 2. Some pts unwilling to comply with physician recommendations. Navigator Relays Treatment Data to Registry Registry Resubmits RQRS Data Monthly 7

8 Objective #1: Achieve 95% compliance with RQRS breast cancer measures iance % Compl May-July Aug-Oct 2011 Nov-Jan Feb-Apr OVERALL AVERAGE RT HT MAC Objective #2: Evaluate feasibility of implementing RQRS/Navigation model in other settings 72% of survey respondents rated model as highly feasible Successful implementation of the model will require: Sufficient staffing & resources (registry, navigation) Change management New processes / procedures Culture shift for staff (registry and navigation) Buy in from stakeholders (physicians, office staff, hospital staff) Objective #3: Evaluate satisfaction with RQRS/Navigation model 70% of survey respondents rated satisfaction level as high with results of study Benefits of RQRS / Navigation Integration: Promotes real time adherence to quality measures Integrates data expertise with clinical expertise Improved communication between registry, navigators, providers, and patients Targets use of navigation resources Potential to enhance patient and physician satisfaction Supports Integrated Model of Care to enhance quality of cancer care 8

9 Reporting System Next Steps: Incorporate RQRS/Navigation model into daily operations Maintain RQRS referrals to navigation Continue Navigation interventions based on alerts and high risk patients, updates to registry Adapt data dictionary/codingsystem for navigation referrals and interventions into MCCM navigation database (enhanced reporting of navigation activities and outcomes) Educate additional navigators and expand model Review opportunities to pursue additional collaborative research to build on this pilot study Present study results in variety of professional forums Reporting System Conclusions The combination of RQRS & Patient Navigation can enhance the quality of patient care and the quality of data collected and reported, and is a feasible model for consideration by other NCCCP sites The role of this model in improving quality and reducing health disparities needs to be explored further in additional/ underserved populations Collaboration with other NCI Cancer Centers can be mutually beneficial, providing increased synergy from combined expertise and resources 9