St. Joseph s Regional Thoracic Program Dr. Yaron Shargall (Head, Thoracic Surgery) St. Joseph s Healthcare Hamilton
SJHH REGIONAL THORACIC PROGRAM Collaboration & Integration Thoracic Surgery - Malignant - Nonmalignant Integrated Comprehensive Care (ICC) Pleural Space & Pulmonary Nodule Clinics
RISK FACTORS 1.4 M HNHB LHIN RESIDENTS HNHB LHIN has higher rates of smoking, heavy drinking and obesity compared to the province 25% daily/occasional smokers 32% overweight 19% obese 27% drink 5 or more drinks (at once) at least 1/month SJHH Regional Thoracic Program One of the largest in Canada 110-130 monthly Lung DAP referrals 759 annual thoracic surgeries 479 Cancer Care Ontario qualifying thoracic surgeries 428 lung 51 esophagus 12 Annual Critical call referrals 108 annual direct transfers to thoracic surgery from other institutions (hospital and ambulatory care)
HNHB Non-Malignant Thoracic Plan
PATIENT JOURNEY -Mr. Jones arrives at local community hospital with difficulty breathing, a cough and weight loss - ED physician consults HNHB nonmalignant thoracic urgent/ emergent algorithm - Manage patient at community hospital with local expertise and resources -Call SJHH (Regional Thoracic Program) for consultation -Call Criticall for immediate patient transfer to SJHH - Direct transfer to SJHH
NON MALIGNANT THORACIC PLAN Established HNHB LHIN Thoracic Steering Group Membership across LHIN (hospital, CCAC, and LHIN) Terms of Reference Non Malignant Thoracic Clinical Service Plan Developed by SJHH and LHIN partners and Approved by HNHB LHIN board June 2011 Developed and communicated non-malignant thoracic urgent/emergent algorithm Developed regional quality metrics (quarterly review) Educational and CME presentations Plan for future service alignment opportunities (i.e. ICC, Pleural Space/Nodule Clinic, EDAP) Partner with Criticall and EMS
Lung Diagnostic Assessment Program
PATIENT JOURNEY -Mr. Smith visits his family doctor with symptoms of weight loss & coughing blood -Family doctor faxes referral to Lung DAP -Mr. Smith receives a phone call within 48 hours from a nurse navigator who triages the referral and arranges for diagnostic tests (i.e. CT scan) -Mr. Smith meets with the Lung DAP team and receives a diagnosis of lung cancer and discusses treatment options with surgeon and nurse navigator -Mr. Smith has a question about his condition a few days later and calls the nurse navigator who is able to answer his question by telephone -On average Mr. Smith would receive lung cancer surgery within 40 days of referral to Lung DAP.
LUNG DAP: HIGHLIGHTS Upwards of 130 referrals monthly Actively manage 250-300 patients at a time 20% of all Lung DAP patients in Ontario 80%+ of Patients Positive or Suspected Cancer Dx 97% Patient Satisfaction 79% of Patients gave the highest possible level of patient satisfaction Scored Higher than Provincial Average on 14/15 Patient Satisfaction Elements Wait Times SJHH: ~40 Days Average & ~26 Days Median Wait Time NHS: ~38 Days Average, & ~20 Days Median Wait Time
LUNG DAP: PATIENT REFERRALS 140 130 120 100 80 89 117 75 60 50 40 42 20 0 17 10 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 Total Referrals SJHH NHS Linear (Total Referrals) Annual Referrals SJHH 861 Source: FIRH LDAP Database NHS 384 Total 1245
LUNG DAP REFERRAL COMMUNITY
Thoracic Program St. Joseph s Healthcare Hamilton
PATIENT JOURNEY -Mr. Smith undergoes lung cancer surgery and stays in hospital for 5-7 days -Mr. Smith receives care from multidisciplinary team and requires respiratory rehabilitation to assist with his recovery -Mr. Smith s outcomes are tracked in the thoracic database to inform quality improvement initiatives and research -A referral is made to oncology or palliative care if required -Communication is provided to Mr. Smith s family doctor and the thoracic surgeon will continue to follow Mr. Smith for 5 years
THORACIC ADMISSIONS 300 Thoracic Inpatient Admissions 1 250 200 150 157 134 141 129 134 138 151 154 152 131 165 165 196 175 223 231 240 209 239 100 50 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 FY 2008/09 FY 2009/10 FY2010/11 FY2011/12 FY2012/13 ¹All admitted patients where MRP is Provider Service Thoracic Surgeon
THORACIC SURGERY VOLUMES 800 Thoracic Surgery: Volumes and CCO Procedures 759 700 620 600 500 400 300 454 247 495 272 513 311 407 479 200 100 0 FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13² Thoracic OR Volumes¹ CCO Qualifying Procedures ¹All patients where procedure performed in the Main Operating Room by Service Provider Thoracic Surgeon. ²Projected based on YTD Data.
CCO QUALIFYING CANCER SURGERIES 600 CCO Qualifying Cancer Surgeries 500 51 400 69 300 200 47 42 52 338 428 Esophageal Lung 100 200 230 259 0 FY 2008/09 FY 2009/10 FY 2010/11 FY 2011/12 FY 2012/13² ¹In order to qualify for CSA funding, the procedure (from a pre-defined list established by Cancer Care Ontario) must be either the primary or secondary procedure performed and the accompanying cancer diagnosis must be the Most Responsible Diagnosis (MRDx). ²Projected based on YTD Data.
CRITICALL REFERRALS
Esophageal Diagnostic Assessment program
PATIENT JOURNEY -Mrs. Lauks visits her family physician with difficulty swallowing and weight loss - Family doctor faxes referral to Esophageal DAP -Mrs. Lauks receives a phone call within 48 hours from a nurse navigator who triages the referral and arranges for appointment with specialist -Mrs. Lauks undergoes testing (i.e. CT, Biopsy etc), meets with the Esophageal DAP team and receives a diagnosis of esophageal cancer. She discusses treatment options with surgeon, oncologist, gastroenterologist and palliative care physician - The nurse navigator will continue to coordinate Mrs. Lauks care throughout her care journey from referral to diagnostics, diagnosis, treatment and homecare
BACKGROUND The estimated 5 year survival for esophageal cancer in Ontario is among the lowest of all cancers at 13%, second only to pancreatic cancer Of resectable esophageal cancers, 5-year survival is 25-40% In Canada, Esophageal Cancer is the 7 th leading cause of cancer death in men, 14 th in women. Between 1986 and 2005, the annual mortality rate has been increasing by 0.7% annually in men, reaching 6.6 per 100,000 in 2005 In Manitoba, 50% of all EC cases were diagnosed at stage IV
BACKGROUND SJHH (HNHB LHIN Regional Thoracic Centre) performed 60+ esophageal cancer surgical cases in 2012-2013 (Apr-Jan) - (data source: WTIS) - Highest number of cases in ON Esophageal Cancer estimate for HNHB LHIN: 112-150 new patients/yr Care pathway for uncomplicated esophageal cancer: 9 months in HNHB LHIN Average of 51 clinic visits for perioperative chemotherapy Average of 61 visits for neo-adjuvant chemo radiation Does not include weekly CCAC visits for 9 and 6 months respectively (Unpublished review of clinic data)
BACKGROUND - EDAP Model based on the Lung Diagnostic Assessment Program (LDAP)- including early detection, diagnosis, treatment & post treatment care Nurse Navigator to provide diagnostic, treatment & community care coordination Multi-disciplinary care model with SJHH, JCC, NHS, BGH, CCAC, McMaster University Comprehensive model- GP S, GI, surgeons, med/rad oncology, palliative care, allied health (SLP/PT/CD/RN..) Clinics offered in Hamilton (St. Joseph s Charlton Site)
EDAP SCOPE First symptom to home or death, which includes: Referrals to DAP made by: oprimary Care, Specialists, JCC, ED, Patient Diagnostics coordinated by DAP Chemotherapy and Radiation (JCC) Surgery Home Care Palliative Care Follow-up
ESOPHAGEAL DIAGNOSIS PATHWAY Presenting symptoms: Known or suspected esophageal mass or cancer Known or suspected gastric mass or cancer Progressive solid food dysphagia Recurrent vomiting of solid food Dysphagia with unintentional weight loss or anemia Concern of upper GI malignancy What information should be included with referral History of patient (risk factors and signs or symptoms suspicious of esophageal cancer) All pre-existing imaging and blood work All relevant medical conditions and medications taken by pt
EDAP OBJECTIVES Earlier Diagnosis To reduce delays on access by improving the referral process from the primary care and specialist physician to SJHH Reduce the worry and wait - patient will be called within 48 hours of referral by nurse navigator Prompt scheduling of initial visit To reduce delays for assessment and diagnostic testing To provide a consistent contact person (nurse navigator) for the entire cancer journey who will coordinate the numerous hospital and CCAC visits To provide patient and family education
EDAP OBJECTIVES To ensure ongoing communication with referring physicians Maintain or improve the patient and healthcare provider experience To increase community awareness and utilization of the DAP to ensure early detection and intervention To grow research opportunities as outcome data is available and access is improved To increase multi-disciplinary collaboration between the JCC, SJHH, NHS, and BGH.
DELIVERABLES Develop esophageal care path Process mapping of current and future state EDAP Nurse navigator and clerk Metrics and evaluation Research Knowledge transfer Timelines
Pleural Effusion & Pulmonary Nodule Clinic St. Joseph s Healthcare Hamilton
PATIENT JOURNEY -Mrs. Kelen is in hospital with fluid around the lung, secondary to cancer -Mrs. Kelen is discharged from hospital and seen in the Pleural Space Clinic where a catheter is inserted and follow-up care is provided in the community -Previously Mrs. Kelen would have stayed in hospital for approx. 18 days, however with the new clinic she will be discharged after 7-9 days with care provided at home by homecare or palliative care team -Mrs. Kelen will continue to be seen in the Pleural Space clinic for follow-up over the next 3 months
MALIGNANT PLEURAL EFFUSIONS (MPE) MPE - common complication of advanced stage malignancies caused by cancers of the lung, breast, and ovary or by lymphomas. Median survival following diagnosis 3 to 12 months Focus of treatment to optimize symptom control and quality of life while minimizing time spent in hospital Evidence that tunneled pleural catheters are a safe and effective outpatient management option for patients with MPE
PULMONARY NODULES Pulmonary nodules - small spots in the lungs seen on x- rays or CT scans Majority of pulmonary nodules represent harmless areas of inflammation or scarring in the lung, BUT may also be lung cancer in its earliest stages or spread from other organs Priority to determine which nodules are potentially dangerous (malignant) Currently no formal systematic mechanism for assessment and follow-up for this low risk group often referred to Lung DAP
Clinic Services include: o Prompt scheduling of initial visit o Timely assessment, diagnosis and recommendations o Management of follow-up visits o Coordination of care with multiple specialists o Ongoing communication with referring physicians o Patient and family education PLEURAL SPACE & PULMONARY NODULE CLINICS CLINICS Partnership between SJHH Respirologists and Thoracic Surgeons Increase capacity in acute care by shifting care from inpatient setting to out-patient clinic o o o Shorten inpatient length of stay Reduce ED visits Reduce readmissions
Integrated Comprehensive Care (ICC) St. Joseph s Health System
ST. JOSEPH'S HEALTH SYSTEM INTEGRATED COMPREHENSIVE CARE PROJECT Project Objectives: Demonstrate the benefits of integrated case management Opportunity to evolve the existing case management model into a patient centered model that follows the patient across the continuum of care Evaluate the impact on patient outcomes, system concerns and patient concerns Three patient groups with broad applicability in Ontario Total Joint Replacements (hip and knee) 520 patients/year Thoracic Surgery, Complex Pleural Space 430 patients/year Chronic Diseases (COPD, CHF) 115 patients/year
PATIENT JOURNEY -Mr. Smith previously would have stayed in hospital for 7 days -As a patient in the ICC project all of his care will be coordinated by an ICC Coordinator -Mr. Smith will be discharged from hospital in 3-5 days and the ICC Coordinator will coordinate his home care and follow-up -Mr. Smith will have some concerns and will call the 1-800 # and speak to his ICC Coordinator who will provide advice and prevent an ED visit by arranging for homecare to visit Mr. Smith that afternoon
Model: Thoracic Surgery Referral to LDAP Diagnosis LDAP Navigator Hospital Team Surgeon Nurse Physiotherapist Allied Health LDAP Hospital Home Home Care Outpatient Clinics Family GP Patient Patient Patient Integrated Care Coordinator
KEY COMPONENTS OF ICC 1. Integrated Care Coordinators 2. Partnership with a service provider in the community 3. Shared electronic health record 4. Timely access to medical care 5. Flexibility in communication: 1. Skype, phone calls 6. Central contact number: Patient access to the team (24/7)
SJHH length of stay by CMG for typical cases : F2011/2012 and Q1 F2012/2013 Length of stay (days) 10 8 6 4 2 0 CMG 112 Open Lung Resection CMG 113 Pleurectomy F2011/2012 Q1 F2012/2013 CMG 114 Endoscopic Lung Resection
Estimated average direct case costs by CMG: F2011/2012 and Q1 F2012/2013 Average estimated direct costs $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 CMG 112 Open Lung Resection F2011/2012 Q1 F2012/2013 CMG 114 Endoscopic Lung Resection
ER VISITS 30 DAYS POST-DISCHARGE Thoracic Surgery 11/12 Q1 12/13 Number of patients 355 101 Number of ER visits* 58 13 % patients with at least 1 ER visit POST-OPERATIVELY 13% 9%
PATIENT SATISFACTION 1. Education and knowledge 2. Interactions and communications 3. Coordination and timeliness of care 4. Access to care (availability) and convenience 5. Support for patient preferences and family involvement 6. Overall satisfaction
Collaboration and Integration - Mapping our Future St. Joseph s Healthcare Hamilton
MAPPING OUR FUTURE 1. Transforming how we work Innovative regional plan that improves the patient experience and is accessible, efficient and integrated 2. Find innovation here Research Education 3. Find community here Engaged people (staff, patients, family, volunteers, students, learners) 4. Find interconnection here Collaboration and integration with partners Respirology, Oncology, Palliative Care, Gastroenterology, Multidisciplinary team, Homecare Niagara Health System, Juravinski Cancer Centre, Brant Community Health System McMaster University, University of Toronto Patients and families
DISCUSSION AND QUESTIONS