November 2017 VOL 8, NO 11

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Research/Quality/Performance Improvement

Helping Breast Cancer Patients Manage Care Transitions Through Patient and Navigator Use of 4R Care Plans, 4R = Right Information/Care/

Julia R. Trosman, PhD, MBA1,2; Jennifer Stein, RN3; Valerie Nelson, MD, MBA4; Jennifer Tepper, MSN, APN, CBCN, CNS4; Cathy Spagnoli, MSHA, RN, CBCN, CN-BN, ONN-CG5; William J. Gradishar, MD, FASCO, FACP6; Claudia B. Perez, DO7; Mikele Bunce, MPH, PhD8; Wayne Pan, MD, PhD8; Liliana Mendoza, RN7; Alma Sotelo, CN-BA7; Swati Kulkarni, MD1; Lynn Galuska Elsen, RN, BSN, IBCLC3; Christine Weldon, MBA2
1Northwestern University
2The Center for Business Models in Healthcare
3Northwestern Medicine
4Northwestern Medicine Lake Forest
5Northwestern Lake Forest Hospital
6Mercy Hospital and Medical Center

Background: Transitions in care require well-managed timing and sequencing of events across specialties. The IOM 2011 and 2013 reports recommend a written care plan at cancer diagnosis to enable cross-discipline teamwork and patient engagement. We developed an innovative approach—the 4R model (4R is Right Information/Care/Patient/Time)—to manage interdependent care and facilitate teamwork with standardized multimodality written care plans. The 4R model of care planning and patient engagement proposed under “NCI ASCO Teams” Project was implemented as a quality improvement with nurse navigators and nurse coordinators at 3 centers—academic, community, and safety net—with patients and their care team. In a pre–quality improvement survey of breast cancer patients at these 3 centers, 45% reported receiving a written care plan, which was not standardized.

Objective: Assess how helpful written, standardized 4R care plans are to breast cancer patients in understanding their overall care and transitions with their care team.

Methods: Conducted descriptive, self-administered survey with nonmetastatic breast cancer patients (stages 0, I, II, III) who received 4R care plans as part of their care. The survey consisted of 18 multiple choice questions, with space for comments with each question. Descriptive statistics were used to analyze results. The quality improvement protocol was approved by the Robert H. Lurie Comprehensive Cancer Center Scientific Review Committee and was deemed non-human subjects research by the Northwestern University IRB.

Results: 68% (109/160) of patients who received a 4R care plan completed surveys. Seventy-five percent of patients reported that, overall, the 4R care plan was useful or very useful in their understanding of their care and managing care interdependencies and transitions. “Did the 4R care plan help you and your care team” in specific aspects was answered as follows: 69% “to understand the whole picture of my cancer care, not just next steps”; 65% “to have a summary information about my care in one place”; 64% “to understand what appointments should happen before other appointments”; 60% “to understand my cancer and my goal of care”; and 58% “to better manage and organize my care.”

Conclusions: Breast cancer patients who received 4R care plans largely found them useful and helpful in various areas of managing and organizing their care with their care team across specialties. Patients provided several suggestions to further improve the usefulness of the 4R care plans. We are incorporating those suggestions along with care team feedback and are expanding the quality improvement of 4R care plans to an additional 10 sites across the United States.

Disclosures: Julia R. Trosman and Christine Weldon have received consulting fees from Genentech. Mikele Bunce and Wayne Pan are employees of Genentech, Inc, a member of the Roche Group, and received stock/options as part of their standard employment compensation.


Trosman JR, Carlos RC, Simon MA, et al. Care for a patient with cancer as a project: management of complex task interdependence in cancer care delivery. J Oncol Pract. 2016;12:1101-1113.

Trosman JR, Weldon CB, Gradishar WJ, et al. Care for a Cancer Patient as a Project: Managing Complex Task Interdependence in Cancer Care Delivery. Presentation at the NCI-ASCO Teams in Cancer Care Workshop. February 2016.

Trosman JR, Weldon CB, Perez CB, et al. Written care plan and patient enablement: pre-implementation data from the 4R in Oncology Project. J Clin Oncol. 2017;35(suppl). Abstract 55.

Weldon CB, Friedewald SM, Kulkarni SA, et al. Radiology as the point of cancer patient and care team engagement: applying the 4R model at a patient’s breast cancer care initiation. J Am Coll Radiol. 2016;13(12 Pt B):1579-1589.

Weldon CB, Trosman JR, Perez CB, et al. How well is interdependent care managed across specialties in breast cancer? Metrics and pre-implementation data from the 4R in Oncology Project. J Clin Oncol. 2017;35(suppl). Abstract 171.

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