The Role of the Master's Prepared Nurse Navigator in Advancing Use of an Interdisciplinary Cancer Appetite and Rehabilitation Clinic Among Patients with Head and Neck Cancer

November 2018 Vol 9, NO 11
Teresa Smink, MSN, RN, OCN
Joan Karnell Supportive and Palliative Care Team, Abramson Cancer Center at Pennsylvania Hospital, Penn Medicine, University of Pennsylvania,
Philadelphia, PA
Debra DeMille, MS, RD, CSO
Joan Karnell Supportive and Palliative Care Team, Abramson Cancer Center at Pennsylvania Hospital, Penn Medicine, University of Pennsylvania,
Philadelphia, PA
Tiffany Hogan, MA, CCC-SLP
Abramson Cancer Center at Pennsylvania Hospital
University of Pennsylvania Health System
Philadelphia, PA
Christine Huntzinger, DPT, CCCE, CCI
Joan Karnell Supportive and Palliative Care Team, Abramson Cancer Center at Pennsylvania Hospital
University of Pennsylvania Health System
and Good Shepherd Penn Partners,
Philadelphia, PA
Brianna Morgan, MSN, CRNP, ACHPN
Abramson Cancer Center at Pennsylvania Hospital
University of Pennsylvania Health System
Philadelphia, PA
Meredith Pauly, MA, CCC-SLP
Joan Karnell Supportive and Palliative Care Team, Abramson Cancer Center at Pennsylvania Hospital
University of Pennsylvania Health System
and Good Shepherd Penn Partners,
Philadelphia, PA
Mary Pat Lynch, MSN, RN, AOCN
Joan Karnell Supportive and Palliative Care Team, Abramson Cancer Center at Pennsylvania Hospital, Penn Medicine,
and School of Nursing,
University of Pennsylvania,
Philadelphia, PA

Background: People living with head and neck cancer incur high risk for symptom clusters involving a cascade of dysphagia, nutrition risk, and deconditioning, followed by often irremediable functional decline.1 Our approach to this symptom cluster, underlying cachexia, and subsequent functional decline is an interdisciplinary Cancer Appetite and Rehabilitation (CARE) clinic disseminated in both publications and presentations.2 Originally designed as a purely rehabilitative service, the CARE clinic now includes prehabilitative assessment and intervention. Our interdisciplinary approach aims to improve nutrition, physical function, symptom management, and quality of life. Supportive care services provided within the CARE clinic include advanced practice nurse assessment and medical management; nutrition assessment and intervention; speech-language pathology assessment, exercise prescriptions, and follow-up; and physical therapy assessment and treatment along with exercise prescriptions.2 Oncology social work and chaplain services are available as needed for individual patients and families. However, patients typically only access the CARE clinic on specific physician or surgeon recommendation when symptoms become burdensome. This pattern of use limits opportunities for prevention, prehabilitation, and early intervention.

Objective: To describe implementation and initial clinical outcomes of a master’s-prepared nurse navigator (MN2) in our interdisciplinary CARE clinic.

Methods: We used a targeted review of both the head and neck cancer and the nurse navigation literature along with building consensus among the head and neck and the supportive care teams to extend the CARE clinic model, addressing patient need and clinician-identified gaps in care delivery.3-6

Results: The gap analysis in our quality data showed lagging referrals and timely access to services provided with the CARE clinic, consistent with broader themes in the literature.4,5,7 Our team identified the necessity of creating a structured means to expedite assessment and access for head and neck patients prior to start of treatment. This expedited tactic employs a prehabilitative principle to improve adherence to treatment, facilitate patient-centered care, and improve patient experience and outcomes. Initial experience with the MN2 role suggests this expedited approach within the CARE clinic model enhances earlier access to rehabilitative services and a trend toward prehabilitative referrals to the clinic. Importantly, patients living with head and neck cancer and their family caregivers spontaneously voice high satisfaction with the CARE clinic and facilitation of their use of this important clinical service provided by the MN2.

Conclusion: Initial implementation experience supports integration of the MN2 within the CARE clinic model, advancing use of both established rehabilitative services and increased use of interdisciplinary prehabilitative assessment and intervention. Patients living with head and neck cancer along with their family caregivers and other members likely value this level of targeted interdisciplinary care. However, our CARE clinic quality data also suggest patients and family members do not understand the value of this interdisciplinary “one-stop shop” compared with ad hoc services with different therapists operating independently in their home communities. Our experience with the MN2 in the CARE clinic suggests this role offers essential education to patients and their families, helping them resolve concerns utilizing our interdisciplinary services.


References

  1. Couch ME, Dittus K, Toth MJ, et al. Cancer cachexia update in head and neck cancer: definitions and diagnostic features. Head Neck. 2014;37:594-604.
  2. Granda-Cameron C, DeMille D, Lynch MP, et al. An interdisciplinary approach to manage cancer cachexia. Clin J Oncol Nurs. 2010;14:72-80.
  3. McMillan SS, King M, Tully MP. How to use the nominal group and Delphi techniques. Int J Clin Pharm. 2016;38:655-662.
  4. Wells M, Semple CJ, Lane C. A national survey of healthcare professionals’ views on models of follow-up, holistic needs assessment and survivorship care for patients with head and neck cancer. Eur J Cancer Care (Engl). 2015;24:873-883.
  5. Salander P, Isaksson J, Granström B, Laurell G. Motives that head and neck cancer patients have for contacting a specialist nurse – an empirical study. J Clin Nurs. 2016;25:3160-3166.
  6. Whittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs. 2005;52:546-553.
  7. Wiederholt PA, Connor NP, Hartig GK, Harari PM. Bridging gaps in multidisciplinary head and neck cancer care: nursing coordination and case management. Int J Radiat Oncol Biol Phys. 2007;69(2 Suppl):S88-S91.
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