Developing Culturally Relevant Breast Cancer Resources—Getting Connected: African-Americans Living Beyond Breast Cancer Catherine Creme Henry, MA1; Arin Ahlum Hanson, MPH, CHES1; Patricia K. Bradley, PhD, RN2; Janine Guglielmino, MA1 1Living [ Read More ]
October 2013 VOL 4, NO 5
Category III: Tracking Processes Across the Continuum of Care
Monitoring High-Risk Breast Cancer Patients in a Community Breast Health Center Through Implementation of a Plan of Care Tool
Sara Hartke, RN, BSN, OCN
Centegra Gaver’s Breast Center
Background: Initiation of a comprehensive high-risk breast cancer program at a community breast health center warranted the need for a plan of care document to monitor patients identified as high risk. Standardized care of patients at high risk for developing breast cancer (lifetime risk >20%) is necessary to ensure the highest quality care possible and can be effectively outlined using a plan of care tool. Objectives: Arrange patients identified as high risk for developing breast cancer so that they can be adequately monitored, and outline their individual prevention plans. Organize communications and eliminate potential confusion among a large multidisciplinary team. Produce greater continuity of care and revise current patient care practices to result in higher rates of screening breast magnetic resonance imaging (MRI) completion and reimbursement. Methods: A plan of care tool was created and reviewed by an interdisciplinary team. Four women identified as high risk for developing breast cancer using the Gail Model were selected and contacted to consent to participate in the pilot. Initial contact interview via e-mail/telephone was then initiated to obtain demographics, health history, and current prevention plan. Contact with the patient’s payer source was initiated once an MRI was requested. The plan of care tool was used to document all conversations and guide the process. Results: Three patients responded and participated. Two patients failed to respond after initial interview, despite several attempts via e-mail and telephone messages. One requested screening breast MRI and obtained preauthorization from a private insurance company but did not complete the examination due to a high deductible on her healthcare plan. Conclusions: The tool effectively monitored interactions with the patients and outlined their individualized prevention plans by those working within the same setting; however, accessibility of the tool became an issue when needing to be accessed by providers that worked at another site within the healthcare system. Therefore, the use of the tool in paper form was not efficient. To make the tool more successful and easily accessible to the entire multidisciplinary team that interacts with the patients, it would need to be converted into an electronic form that can be accessed from any of the healthcare system sites. A small sample group and a time constraint of 10 weeks negatively impacted the outcome of the study. Lack of continued participation in the project resulted in inconclusive data. It is important to note that it is not unusual for this population of patients to need more time to accept the status of being considered high risk for developing breast cancer and what that means to them. Lack of completion of screening breast MRIs was a poor representation of improvement in the quality of care that the patient received and another method (perhaps a qualitative questionnaire to evaluate the patients’ perspective of the interactions and effects of the study would be a better option as patient satisfaction is a component of quality of care).
Role of Patient Assessment, Navigation and Education in the Identification of Oncology Patients in Need of Rehabilitation Therapy
Barbara R. McHale, RN, BS, OCN, CBCN; Sabrina Mosseau, RN, BS, OCN; Paula Burnor, PT, MS; Nancy Clemente, OTR/L; Anna Feldman, RN, OCN; Leslie Hurley, RN; Lauren Marcus, SLP; Denise Morris, PT; Sandra Sanderson, MSPT, CLT-LANA; Kelly Simpson, RN, OCN
Samaritan Hospital Cancer Treatment Center, St Peters Health Partners
Background: At Samaritan Hospital Cancer Treatment Center, we realized that patients were not being referred to comprehensive therapy services in a timely manner. In our pursuit of patient-centered care, we identified the need for patients who were undergoing treatment, recently completed treatment, or living with unresolved issues as a result of their cancer treatment to have access to oncology rehabilitation. These unresolved issues include, but are not limited to, musculoskeletal pain, decreased strength and endurance, balance problems, fatigue, vertigo, limitations in range of motion, and speech/swallowing issues. In 2012, meetings began to implement a highly trained, multidisciplinary oncology rehabilitation team that utilized evidence-based practice and measured patient outcomes. This team explored current and future state options. Because we are a small community-centered practice, it was cost-prohibitive to purchase and implement a national program. A service inventory was undertaken to identify current strengths and programs, including a robust physical, occupational, and speech therapy program; highly specialized lymphedema therapists; myotherapy; Healing Touch; a Pink Pilates program; and massage therapy. The major areas of concern were improving patient identification and access to oncology rehabilitation, assigning a navigator as point of contact and care coordination, educating patients and providers on available services, and development of a physical, occupational, and speech therapy evaluation and treatment care plan. This care plan is currently being piloted at Samaritan Hospital Cancer Center, but will be initiated at other centers across St. Peter’s Health Partners. Also noted as important was incorporating evidence-based outcomes in the oncology rehabilitative treatment of our patients. It is our goal to assist our patients in receiving treatment services in an equitable and timely manner, to remove barriers to their care, and to educate patients, thereby improving outcomes. Objectives: (1) Develop and implement a process to identify impairments and streamline patient access to oncology rehabilitation; (2) incorporate a navigator in patient care from time of initial diagnosis through the continuum of care to assist in breaking down barriers to rehabilitation access; (3) encourage physician and nursing awareness of the need for oncology rehabilitation through focused education sessions; and (4) increase the percentage rate of oncology rehabilitation consults through a systematic approach to care. Methods: (1) Implemented a patient care plan to identify physical and occupational impairments. (2) In conjunction with the rehabilitation departments, a functional reference sheet was designed to be used as a guideline for standardized assessment. (3) Edited the medical oncology nursing assessment flow sheet to identify parameters for patient deficits in the areas of range of motion, gait, activities of daily living, dizziness, and swallowing. (4) Physician order sheet was updated to include referral information for oncology rehabilitation. (5) Standardized process that at each patient visit the oncology nurse utilized the functional reference sheet in conjunction with the nursing assessment form to identify patients with impairments. (6) Development of a standardized communication tool to track and trend oncology rehabilitation referrals and documentation of patient outcomes. (7) Worked collaboratively with “TruJoy” to place their bags in our preadmission testing department, to be given to postoperative mastectomy patients. These bags included educational materials, a reacher, specialized axillary pillows, a stress ball, and nonchemical soap and lotion. Our patients also received postmastectomy camisoles. Results: Implementation of this process has shown a 10% increase in patient referrals from the cancer center to the rehabilitative program in a 3-month interval compared with the previous year. The increase in patient referrals has led to an increase in volumes and downstream revenue for our facility. This process has allowed our facility to create a reimbursable oncology rehabilitation program. With the identification of impairments, the timely referral to our rehabilitative program, and the determination by our therapists of the patients’ needs, a treatment plan is developed. This process has been instrumental in promoting survivorship care through improved access to services. Conclusions: Oncology rehabilitation is a valuable service that positively impacts patients’ functional status, both physical and emotional. This program was implemented on February 1, 2013, and through evaluation, tracking outcomes, and a final analysis, we will prove the impact of a standardized functional assessment of all of our patients. We have shown that it can be implemented in a community-based hospital with minimal cost through utilization of services and programs already available. With patient-centered, coordinated care we expect to see improved patient satisfaction in care delivery at our center.
Across the Cancer Continuum: Tracking Processes Across the Continuum of Care
Melissa Andres, BSN, RN, OCN, CBPN-C; Erika Kacer, BSN, RN, OCN
St Vincent Health
Objectives: The overall mission of the St Vincent Cancer Care program is “to be the first choice provider of the most advanced cancer care, delivered by a highly skilled and compassionate team, serving in partnership with our patients and their loved ones, through and beyond their cancer journey.” To meet this mission, St Vincent had a vision to transcend cancer care to support the mind, body, and spirit of each person we serve throughout the continuum of their cancer journey. Background: In 2010, St Vincent piloted patient navigation to serve and support those patients with breast cancer. The goal was to develop a sound process for navigation, monitor the benefits and outcomes of navigation in this patient population, and then expand to all other cancer sites. In 3 years, the St Vincent Cancer Care program has expanded not only navigation, but has also added an outreach coordinator, imaging navigator, inpatient navigator, survivorship services, and a supportive care program. Methods: The breast navigation pilot was developed to proactively navigate patients with breast cancer. Rather than waiting for referrals, the navigator connected with patients at the time of diagnosis. The volume increased from 14 new referrals in the first quarter of 2010 to 133 new referrals by the end of 2010. Results: This showed the need to add additional navigators to meet the needs of our patients. We expanded our pilot to include all cancer sites, and our volume of referrals for navigation services increased from 133 in 2010 to 277 in 2011. In 2012, we had 804 new referrals, and in 2013 we have had 775 new referrals in the first 3 quarters. As our volume increased, we added additional navigators. Today we have 6 outpatient navigators and 1 inpatient navigator. In November, 2011, St Vincent also added survivorship support groups for patients and caregivers as well as a creative expressions art program, and the number of participants for survivorship services has increased 186% in 1 year.
Assessing Breast Cancer Survivorship Needs in the Community
Pamela Goetz; Lillie Shockney, RN, BS, MAS
Johns Hopkins Medicine, Sibley Memorial and Suburban Hospitals
Objectives: As community hospitals in the Johns Hopkins Medicine network, Sibley Memorial Hospital and Suburban Hospital recognize the importance of meeting the needs of patients with cancer after completing active treatment. With dedicated staff to develop survivorship programs following the Hopkins Baltimore, Maryland model that also address the specific needs of people in our service areas, focus groups were conducted with breast cancer survivors to determine what gaps in services they experienced, what their ongoing health concerns are, and what survivorship programming would be of interest to them. Methods: Women with stage 0 to stage III breast cancer were recruited by providers at the 2 hospitals. Focus groups took place at each hospital and were facilitated by the Director of the Survivorship Programs at Johns Hopkins and the Oncology Survivorship Coordinator at the community hospitals, with a total of 13 survivor participants. The women completed a questionnaire to obtain “hard” data about treatments received, side effects, and interest in various survivorship programming. The facilitator led the group through a series of questions in an open-ended discussion. Results: Self-advocacy is recognized as a necessary skill to get access to care, identify reliable information about cancer, and find support resources. Women wished for more sensitive and clearer communication from their providers. Sexual health problems are significant, yet no provider raised these as potential side effects or what to do about them. More than 75% of the participants have struggled with anxiety, depression, fatigue, insomnia, memory problems, skin changes, and vaginal dryness. Close to 70% worry about recurrence. Several of the participants expressed the need for case management, family support, and clarity about who, among their many oncology providers, they should go to for survivorship care. Conclusions: The hospitals’ care teams are dedicated to meeting the survivorship needs of our patients with breast cancer, and have begun to develop educational programs and offer navigation along the continuum that will address women’s needs, voiced during the focus groups. A 1-day survivorship retreat will take place in September, with presentations designed to provide practical help on how to regain control after completing active treatment for breast cancer. The agenda includes talks by experts on reclaiming your life, coping with late effects of therapy, maintaining a healthy weight through nutrition and exercise, reconnecting with a healthy sex life, learning about integrative health modalities, and hearing from a survivor panel on how they moved on. Results will be shared on the poster.
Novice to Expert: Training Methods for the Cancer Center Treatment Navigators at Boston Medical Center
Katie Finn, BA; Sheldon Reeves, AA; Kathryn Ankner, BA; Juliana Merhaut, MA; Robyn Souza, RN, MPH; Chris Andry, PhD; Kathleen Finn, MSN, NP
Boston Medical Center
Boston Medical Center (BMC) is a private, nonprofit academic medical center with approximately 65% of patients coming from neighborhoods with the highest levels of mortality and health disparities. At BMC, Cancer Center Treatment Navigators (CCTNs) have succeeded in becoming valued members of the cancer center, helping patients with complex needs work their way from diagnosis into survivorship. Currently 4 CCTNs collectively receive approximately 36 new referrals per month with an average monthly workload of 80 patients per CCTN with approximately 3 identified barriers per patient. A key component to the success of this program lies in the comprehensive training curriculum developed by the CCTNs and their nurse mentors. This training program became a standardized best practice in 2011 for BMC’s CCTNs.
The CCTN training curriculum is divided into 3 phases. The first phase begins with general hospital orientation, trainings, and an introduction to the CCTN’s preceptor. The novice CCTN will then tour the hospital with their preceptor in order to understand the potential challenges a patient may face when navigating a large hospital campus. The next phase focuses on providing an overview of BMC’s cancer program with an emphasis on understanding cancer and the potential impact the disease can have on a patient and their family. The novice CCTN will shadow specialties such as social work, clinical research nurses, and treatment nurses. The CCTN attends tumor boards, receives a comprehensive review of treatment algorithms, Standard Operating Procedures, and attends cancer support groups. After each meeting with a specialist or attendance at a group, the novice CCTN will meet with their preceptor to review and discuss the CCTN’s understanding of what was learned and how to incorporate that knowledge into their role. The third and final phase of training includes specifics such as interviewing patients, identifying and addressing barriers to care, utilizing resources, documenting in the electronic medical record, customer service, and telephone triage. The CCTN spends a significant amount of time shadowing the experienced CCTN in all areas of the role. At the end of this phase, the CCTN will begin working independently under direct observation of their preceptor.
In conclusion, the curriculum is designed so that each phase of learning builds on the last, incorporating new skills with ongoing discussion between CCTN and preceptor. Competencies are assessed throughout the training period and include direct observations, quizzes on oncology knowledge, role-playing, and case presentations including review of chart documentation. In addition, continuing education is provided on an ongoing basis by the cancer care team members as well as by attendance at national conferences. A standardized training curriculum and ongoing education is paramount for a successful oncology patient navigation program.
Initial Results Tracking Patient Satisfaction in an Oncology Navigation Program
Dorothy Morrone, RN, MS, OCN; Diane McHugh, RN, BSN, OCN; Laura Beaupre, RN, BSN, OCN, CBPN-IC;
Kathleen Sevedge, RN, MS, AOCN; Jane Zubia, RN, OCN, CBPN-IC; Raizalie Roman-Rosado, RN, BSN, CMSRN;
Maritza Y. Chicas, RN, BSN, PCCN
Lehigh Valley Health Network
Background: Patient satisfaction is an important outcome measure in oncology navigation. Our cancer center participates in the National Cancer Institute Community Cancer Centers Program (NCCCP), which has a focus on patient navigation. The Navigation Assessment Tool developed by the NCCCP includes a section on Quality Improvement Measures supporting the importance of utilizing patient satisfaction data. The RN navigation team at Lehigh Valley Health Network developed and implemented a satisfaction survey in English and Spanish to evaluate aspects of navigation. Surveys were returned from 60 patients over a 6-month period. Objective: To evaluate patient satisfaction with navigation and use for process improvement. Methods: Surveys from 4 NCCCP sites and Press Ganey questions used in the Cancer Center were reviewed. Navigators identified questions related to aspects of navigation, including communication, care coordination, referral to services, and support; operational issues such as ease of access to navigator and timely return of phone calls; and customer service items including courtesy and value of the navigator, and suggestions for improvement. Ten questions from NCCCP satisfaction surveys were incorporated into our survey. Eight additional questions were created. No Press Ganey questions were used. The final survey contains 18 questions: 15 using a 5-point Likert scale; 1 regarding number of contacts with the navigator and 2 fill-ins. In January 2012, upon discharge from navigation, patients were mailed a satisfaction survey, cover letter, and addressed, stamped envelope. Surveys returned between January and June 2013 were reviewed and tallied. Results: A total of 394 surveys were mailed to patients. Sixty were returned (15% response rate). The average score of all questions was high; 4.7 of 5. The range of scores was 4.51 to 4.89. High-scoring questions related to customer service: courtesy; being treated like an individual; and overall experience with the navigator. Lower-scoring questions were related to aspects of navigation: “The support I got from my navigator helped me complete my treatment”; “My navigator provided support to my family when needed.” These questions also had a higher response of “nonapplicable.” The fill-in question, “What did you like best about having a navigator?” received many positive comments. There were 3 suggestions for improvement. Conclusions: Overall patient satisfaction is high. The navigation team reviewed the results and chose 1 item for process improvement that was incorporated into their performance evaluation. Goal: Improve timeliness of phone calls to patients. The navigation team will review patient satisfaction every 6 months. Funded by National Cancer Institute Contract No. HHSN261200800001E.
Mapping: A Quality Improvement Tool for Patient Navigators
Heather Kapp, LICSW, MPH; Monica Dreyer, MA; Diana Garcia, BS; Leshia Hansen, RN, BSN; Elizabeth Hatcher, RN, BSN; Eva Ruiz, BS; Mandi Pratt-Chapman, MA
George Washington University
Background: The GW Cancer Institute, in partnership with the GW Medical Faculty Associates and the GW Hospital, has built a comprehensive patient navigation service to assist patients across the cancer continuum. Three lay navigators work as a team with a nurse navigator, a cancer center social worker, and a survivorship navigator to assist patients throughout their cancer experience. Objective: In 2013, the team embarked on a process mapping project for the breast cancer patient treatment flow. The objective was to identify gaps in care to implement quality improvement projects executed by the navigators. Methods: The navigators separately mapped the process in each clinic where they work. When completed, the patient flow across the continuum of care for the patients with breast cancer had been documented. The navigators met as a team with all the process maps to discuss how to best utilize each navigator without duplication. The team examined how referrals are made, when to refer to survivorship, the best process for barriers to care and distress screening, etc. Based on these discussions, quality improvement initiatives were prioritized and meetings were held with key stakeholders for buy-in and support. Results: Each navigator has quality improvement projects that stemmed from the process mapping, which will improve referrals to psychosocial support services and ensure patients’ access to follow-up care. A few of the quality enhancements are the following: (1) Improving loss to follow-up by calling patients after a missed screening test or any missed follow-up to inquire about barriers to completion of the diagnostic process. (2) Developing and implementing an educational presentation to decrease incorrect referrals with community clinics and to make the diagnostic process smoother for patients. (3) Implementing a process of mailing invitations to patients to offer them a survivorship clinic appointment. (4) Establishing a process for referring patients with barriers to care to the radiation oncology navigator. Conclusions: Mapping the breast patient’s process along the continuum helps prioritize quality improvement (QI) projects, defines how navigators can contribute to QI, and helps ensure navigators are focused on true navigation. We are early in the process of implementation; however, we believe this will improve patient care. As part of this process, a distress screening protocol has been implemented in partnership with the cancer center social worker, and the survivorship navigator has already noted an increase in referrals to the survivorship clinic. Key to the success of this project is improving the data tracking and measurement of the QI projects. GW Cancer Institute is currently working to implement an electronic database that will be critical to tracking the success of these quality improvements.
An Outcomes Management Process for Navigation
Sharon Bartelt, RN, MSN, MBA, OCN, CPHQ, CSSBB
Gibbs Cancer Center & Research Center
Background: Return on investment (ROI) is ever more critical in an environment of minimal healthcare dollars and limited resources, including full time equivalent allocation—to that end, a current database at Gibbs Cancer Center was utilized and further developed to track the interventions/referrals of oncology nurse navigators. The database allows nurse navigators to enter patient-specific data that track outcomes metrics, which in turn enables leadership to realize the value, both monetarily and in patient satisfaction outcomes. Objective: To develop a process of tracking outcomes metrics related to disease-specific nurse navigators in a community cancer center setting. Methods: Implementation of a team approach consisting of nurse navigators and the MIDAS database system administrator to brainstorm and develop the MIDAS Community Case Management module currently in use at Spartanburg Regional Healthcare System as the method of tracking navigation data. Results: The MIDAS Community Case Management module now has the ability to track each disease-specific nurse navigator datum related to interventions/referrals (ie, 6200 interventions/referrals by breast navigators in 2012; 4300 referrals/interventions by lung navigators in 2012), number of navigated patients by race, disease-specific navigated patients by cancer and noncancer, case hours by each disease-specific navigator, new patients, follow-up patients, patients presented at the multidisciplinary planning conferences, and patients who were admitted to the hospital or had an emergency center visit during navigation. Conclusions: The MIDAS database clearly has been invaluable in tracking metrics related to ROI for each disease-specific navigator. As a result, a cost-savings can be calculated from the MIDAS data and can validate the nurse navigator role at Gibbs Cancer Center. Outcomes metrics include: Operational Indicators: Volume, Workload, Race/Ethnicity Referral origin. Quality Indicators: Patient Satisfaction Data, Physician Satisfaction Data, Clinical Trials, Multidisciplinary Coordination. ROI: Inpatient, Admissions, Observation Days, Navigation Driven Volume.
Assessing Prostate Cancer Survivorship Needs in the Community
Pamela Goetz; Lillie Shockney, RN, BS, MAS
Johns Hopkins Medicine, Sibley Memorial and Suburban Hospitals
Objectives: As community hospitals in the Johns Hopkins Medicine network, Sibley Memorial Hospital and Suburban Hospital recognize the importance of meeting the needs of cancer patients once they complete active treatment. With dedicated staff to develop survivorship programs, following the Hopkins Baltimore, Maryland model that also address the specific needs of people in our service areas, focus groups were conducted with prostate cancer survivors to determine what gaps in services they have experienced, what their ongoing health concerns are, and what kind of programming would be of interest to them. Methods: Participants for the focus group were recruited by physicians, social workers, nurses, and navigators at the 2 hospitals. Separate prostate cancer focus groups took place at each of the hospitals and were facilitated by the Director of the Survivorship Programs at Johns Hopkins and the Oncology Survivorship Coordinator at the 2 community hospitals. A total of 10 survivors, with 6 wives or partners attended. Of the 10 men, 2 had a local recurrence and 2 had advanced disease. The participants completed an anonymous questionnaire to obtain “hard” data about treatments received, side effects and level of impact, and interest in various survivorship programming. The facilitator led the group through a series of questions in an open-ended discussion. Results: In spite of spending a lot of time researching options, men often experience challenges in decision-making about treatment. One hundred percent of the men struggle with side effect treatment. Sexual dysfunction and/or incontinence are primary side effects that plague men, and they persistently seek ways to either prevent or resolve these problems. A majority of the men worry about recurrence or disease progression. The participants expressed a need for interdisciplinary, one-on-one decision-making support, in-depth posttreatment side effect management, and interest in evidence-based programs that would reduce stress, manage late and long-term treatment effects, help with stress reduction, or reduce risk of recurrence. Conclusions: The mission of the hospitals’ cancer care teams is to address the ongoing healthcare needs of our patients with prostate cancer, and will use the data from these focus groups to promote patient self-advocacy and to provide programs, education, and services to meet the needs of patients beyond active treatment. Quarterly survivorship education programs are planned, with the first addressing sexual health issues scheduled for October 2013.
Developing an Oncology Nurse Navigation Process Along the Continuum of Care at the New Calaway Young Cancer Center at Valley View Hospital
Mary Crann, RN, MSN, OCN; Diane Carnoali, LSW; Bart Carnoali, RN, BSN, MHSM, PMP
Calaway Young Cancer Center at Valley View Hospital
Objective: It is the desire of the Calaway Young Cancer Center at Valley View to provide timely, appropriate care and reduce disparity for patients with cancer through the development of an oncology nurse navigator (ONN) program. Background: A Community Needs Assessment, in conjunction with Cancer Committee leadership, served as a building block for the opening of a new cancer center with an ONN program. The Cancer Committee decided to initiate the ONN program with newly diagnosed patients with breast cancer and end with the presentation of a Survivorship Care Plan at the conclusion of active treatment. Methods: An intake form together with National Comprehensive Cancer Network Distress Tool will be used to identify and track barriers. Data will be collected to measure timeliness of care using American Cancer Society benchmarks. Metrics will be analyzed to measure success in reducing disparities. Reports will be generated and presented to the Cancer Committee leadership on an annual basis. A subcommittee was formed to develop an algorithm for the nurse navigation process along the continuum of care. The process starts at diagnosis when the ONN receives a report of positive pathology. The ONN contacts the referring physician for permission to contact the patient, and within 3 days of diagnosis arranges for initial consult if one has not been made. Barriers are identified and social work is notified of the newly diagnosed patient. The ONN accompanies the patient to the first appointment, reviews plan of care, makes additional appointments, educates, and empowers the patient to overcome barriers. All newly diagnosed patients with breast cancer are presented at weekly multidisciplinary team meetings and referrals are made for ancillary services. The ONN continues to educate, identify, and work on barriers along the continuum of care. At the end of active treatment, the patient is presented with a Survivorship Care Plan. The process will be reviewed by a subcommittee, and any required changes will be presented to the Cancer Committee. Conclusions: The ONN program will help patients receive timely care and reduce disparities for patients with cancer in the community. The plan is to expand the program into other specialty areas, giving all newly diagnosed patients with cancer better access to care. The ONN program is a key step in obtaining American College of Surgeons Commission on Cancer accreditation.
Building a Continuum of Care: The Breast Channel
Amy E. Rettig, MSN, MALM, ACNS-BC, PMHNP-BC, CBCN®
Ohio State University Medical Center
Background: In the ever-changing world of breast oncology, keeping up to date requires much independent study for the nurse navigator. Even comprehensive breast care centers, resource rich with interdisciplinary care teams available within one building, may have difficulty coming together as one larger team instead of independent disciplines. Two years ago, the Breast Cancer Clinical Nurse Specialist developed and implemented a weekly, 30-minute, informal, evidence-based forum for all healthcare persons involved in the breast cancer continuum of care to help the interdisciplinary team keep current. “The Breast Channel” is now moving forward into its third year full of potential. Objective: Attendees will understand how The Breast Channel can create an integrated, educated, and patient/family-focused staff caring for our patients with breast cancer. Nurse navigators will understand the advantages of having a well-informed continuum of care team. Methods: A 5-week focus group determined the optimal mechanism for providing education across a continuum of care. Real-time, audioconferencing with subsequent podcasting was found to be the most accessible and reasonable for all staff. New and emerging technologies provide the means for audioconferencing, podcast editing, and a podcast repository. Often these technologies are free to users. Results: A survey of the continuum of care team discovered that The Breast Channel, starting as a weekly, 30-minute teleconference podcasted for future listening, is now used for on-boarding new staff, Certified Breast Care Nurse® examination review, professional development, interdisciplinary collaborations, and patient education. An Tracking Processes Across the Continuum of Care
independent reviewer evaluated 88 podcasts for key elements important for public listening: delivery, speech clarity, vocabulary, and technology. Twenty-two were considered immediately suitable for public listening with many others eligible after editing. Conclusions: Keeping the healthcare team, including nurse navigators, current in the rapidly changing oncology world has been facilitated by The Breast Channel. New and emerging technologies provide the means to create accessible information to all persons involved with the care of patients with breast cancer. Integrating different disciplines, including nonclinical departments, can be facilitated by simple audioconferencing and podcasts. Oncology nurses have used this forum to review for certification in breast care as well as to develop their professional careers by presenting on current oncology nursing topics. Other disciplines have used The Breast Channel to on-board new staff and to enhance professional development. Future opportunities include allowing patients to access podcasts, conference information dissemination, and replication in other cancer continuums of care.
Developing a Cancer Rehabilitation Service Line
Bassett Healthcare Network
Background: The Bassett Cancer Institute (BCI) is a comprehensive community cancer center in New York with approximately 1225 analytic cases per year. In 2011, BCI expanded its survivorship services with a strong nurse practitioner leader who then took another position in 2012. The survivorship program languished until a new nurse was hired to lead the program. Objective: Many survivorship programs are in flux due to changes in leadership, and this abstract describes how one program has faced this challenge and is now rebuilding. Methods: BCI has a survivorship program with a core component of a cancer rehabilitation service line through the STAR Program® certification—launched in January 2012. The program had a robust beginning under the leadership of a nurse practitioner; however, after her departure in June 2012, the program languished, with only 16 referrals through year-end. BCI recognized that a strong leader was needed to continue the program and recruited a nurse with extensive experience in administration and community outreach who took on the role of revitalizing the program in December 2012. The multidisciplinary team was assessed, and new members were identified to ensure there was adequate representation from all disciplines. The team meets monthly to network, share experiences, break down barriers, and seek innovative ideas in an effort to increase referrals to the program. To increase awareness of the program, the new manager developed a presentation outlining the program benefits and began providing education to referring clinicians throughout the region. To streamline the referral process, there is a STAR Program referral in Epic available to the entire network. The program is focused on patient-centered care, and survivors have been invited to give feedback regarding the services. Results: August 2013 year-to-date rehabilitation referrals are 38 (an increase of approximately 140% compared with a similar interval in 2012), and projected referrals for 2013 are anticipated to be at least 75 new patients. Many of the new referrals have come from physicians who had never referred to the program before, suggesting widespread adoption among referral sources. Conclusions: Survivorship programs benefit from dedicated leadership and may suffer from staff turnover. New leaders may face significant challenges when attempting to revitalize a program after a change, and a strategic approach is helpful. BCI is focusing on screening protocols, updating website content so that survivors learn more about these services, giving formal lectures and having informal discussions with referral sources (particularly focusing on physicians and nurse navigators), and assessing the physical outcomes as well as the patient satisfaction outcomes of the people who go through the program.
Centralizing Imaging Review Prior to Initial Consultation for Breast Cancer Treatment
Fran Spiro, RN, BA, BS, OCN
Memorial Sloan-Kettering Cancer Center
Background: The Breast Surgery Service at Memorial Sloan-Kettering Cancer Center has 9 surgeons who see an average of 85 new consults each week. Patients are asked to provide all breast imaging studies from the past 3 years, including mammograms, sonograms, and magnetic resonance images for our radiologists to review. New patients frequently arrive having had biopsies elsewhere, with pre- and postprocedure imaging and reports. Traditionally, our Physician Referral Service asked patients to bring imaging materials to the consult appointment. Drawbacks to this process included receipt of incomplete imaging materials, making it impossible to form a definitive surgical plan; disruption of patient flow in the clinic, adding to wait times; and the need for repeat visits for patients to deliver missing studies, repeat imaging, and/or additional biopsies preoperatively. Objective: A new Early Film Submission (EFS) process was initiated in January 2011. The goal was to have more complete information available to the surgeon before a new patient’s visit. This would allow for scheduling of any additional imaging or biopsies that were recommended on the day of the consultation, decrease patient wait times in the clinic, and facilitate formulation of a definitive surgical plan. Methods: New patients were asked to deliver imaging studies to the surgeon’s office 3 to 7 days before the initial consultation. Review of these cases was centralized through 1 nurse well versed in the diagnosis and surgical treatment of breast cancer. Her clinical expertise enabled her to assess the completeness of the film package, identify how best to obtain missing information, and guide newly diagnosed—often overwhelmed—patients through the maze of gathering clinical information for the consultation. Results: Centralizing the process through an experienced clinician resulted in standardization and improved accuracy of information provided to the reading radiologist and increased the number of radiology consult reports available for the surgeon at new visits. There was a significant decrease from 34 to 20 days between the initial patient visit and the date of surgery. Office practice nurses, radiologists, and surgeons reported increased satisfaction with the EFS process in surveys taken at 3 and 6 months postinitiation. These positive findings increased use of the EFS process from 48% to 66%, as reflected in data collected in the first quarter 1 year before and 1 year after initiation. Conclusions: Having an identified clinical nurse for film review prior to breast cancer consultation resulted in better communication and coordination between the surgery and radiology departments, decreased disruptions to patient-focused nursing care during clinic, and shortened the time for a new patient to have surgery. Additional resources would allow for increased EFS volume, increased data assessment, and ability for the nurse to expand patient outreach.
Arizona Young Breast Cancer Survivor Support Initiative: Needs Assessment
Mikala Edwards, MPA; Alisa Domb, RN; Sherry Gage; Paulla Miller
John C. Lincoln Health Network
Background: More than 400 young women are diagnosed with breast cancer each year in the state of Arizona. Young women face many unique challenges related not only to their disease and treatment, but also to their overall health, career, fertility, personal relationships, and finances. The Arizona Young Breast Cancer Survivor Support Initiative is a cooperative agreement between the Centers for Disease Control and Prevention and John C. Lincoln Health Foundation. The goal of this initiative is to evaluate Arizona programs and services that support young (<45 years of age) breast cancer survivors, their families, and caregivers. Objectives: (1) Identify needs of young breast cancer survivors throughout the state of Arizona; (2) Examine existing programs and services; and (3) Develop new programming to address unmet needs of this group. Methods: Establish the Arizona Young Breast Cancer Survivors Outreach Coalition and Arizona Breast Cancer Resource Guide committee to identify and review existing community services. Both of these groups are comprised of the target population, breast cancer organizations, and community members who represent the ethnic and racial diversity from the urban and rural populations of Arizona. Members of these 2 groups identified individuals through personal and professional contacts and distributed the
online, www.surveymonkey.com/s/azbreastcancer, and paper versions of a needs assessment survey to all counties of the state. In addition, John C. Lincoln’s breast health awareness partnership with the local media known as “Buddy Check 12” publicized the survey and provided a link to the online survey. The hard copy survey was translated into Spanish. Results: One hundred seventeen surveys were completed and reviewed. Identified gaps in services were understanding diagnosis and treatment options; availability of resources and financial assistance; addressing feelings of negative body image, sexuality, and relationships after cancer; finding support for friends and family, and maintaining relationships; and connecting with other young survivors. Conclusions: Based on the results of the needs assessment, the initiative will host and provide programmatic materials and education pertinent to the geographic area, cultural background, and age of those constituents. In addition, education will be provided to the medical community, including patient navigators regarding available resources for young survivors. In addition to the outreach and personal programming, an online resource guide was developed and shared with sites through Arizona, www.azbreastcancer.org.