At the recent AONN+ Annual Conference, experts in oncology navigation convened virtually with conference attendees to offer their insights in furthering the efficacy of navigation. This monograph will review the proceedings from 4 key sessions covering the timely topics of telehealth, mental health and the oncology patient, prehabilitation and rehabilitation, and value-based oncology care.
The COVID-19 pandemic completely changed oncology care all over the globe. With lockdowns and travel restrictions in place, as well as widespread fear of contracting the virus preventing people from seeking out healthcare, cancer providers and patients had to rapidly adapt to the idea and practice of telehealth. Rules regarding the provision of telehealth were quickly changed, and waivers were issued to allow for patients to continue receiving cancer care at home. But although these licensure requirements will likely tighten again after things go back to “normal,” it seems that telehealth in oncology is here to stay.
In addition, according to Jennie R. Crews, MD, MMM, and Janelle Wagner, RN, OCN, both from Seattle Cancer Care Alliance, telehealth in oncology is likely to expand to aspects of cancer care beyond the patient/provider visit, potentially into supportive care, genetic counseling, survivorship, and navigation.
To understand telehealth, it’s important to know a few basic terms. First, telehealth uses both video and audio (distinguishing it from a regular telephone call). The “originating site” is defined as the location of the patient at the time the service is rendered, and the “distant site” is the provider’s location at the time service is rendered.
Historically, telehealth has not been widely adopted in healthcare, particularly in the field of oncology. This is due to a variety of barriers, many of them around reimbursement issues, an inability to demonstrate a return on investment, state and federal regulations, logistical considerations like scheduling, institutional issues with credentialing and oversight, and a lack of provider and patient buy-in to this type of care.
But despite these barriers, the use of telehealth in oncology was rapidly adopted in the midst of the pandemic, and based on how quickly both providers and patients were able to acclimate to this modality of cancer care, legislative and regulatory efforts are now underway to make sure it remains a viable option for patients post-COVID.
In March 2020, the World Health Organization declared COVID-19 a pandemic, and at the same time, President Trump declared a national emergency. This set into motion some important allowances for the Centers for Medicare & Medicaid Services (CMS), particularly the 1135 Waiver, which allowed for the lifting of geographic restrictions on originating sites. In addition, it allowed for both new and established patients to be seen in telehealth visits (this was previously only allowed for established patients). Finally, it allowed for Medicare payment parity between telehealth and in-person visits, so providers could be reimbursed at equal rates.
A second round of waivers issued shortly thereafter, on April 30, 2020, allowed for an expanded definition of “eligible provider,” which meant patients could receive telehealth from providers such as physical therapists and occupational therapists. However, this expanded definition did not include other providers like pharmacists and nurses.
The additional waivers issued in April also recategorized CPT codes for telephone calls, hereafter recognizing them as telehealth. This allowed hospitals to bill for facility fees even when the patient was at home, and allowed providers to bill for total time for a telehealth visit, (including preparation, visit, care coordination, and documentation) for telehealth.
Regulatory changes were also enacted by individual states. Medicaid was allowed to cover telehealth services on a state-by-state basis without seeking federal approval, many private payers expanded their telehealth benefits, and a number of states waived or offered expedited licensure requirements so that telehealth could be practiced across state lines.
Since the situation with COVID-19 was and still is so fluid, providers should always check their own state’s regulations and legislation, as well as payer websites for up-to-date information regarding telehealth rules and requirements. The Center for Connected Health Policy (www.cchpca.org/resources/covid-19-telehealth-coverage-policies) and the Federation of State Medical Boards (fsmb.org/advocacy/COVID-19) offer updated resources for providers.
Some of the waivers issued by CMS, particularly the originating site waiver, will require legislative action to become permanent. However, a number of legislative bills have been introduced at the federal level to help make telehealth more easily accessible after the pandemic is over.
In the wake of COVID-19, the field of telenavigation became another rapidly expanding area of oncology care. Telenavigation is defined as care coordination by the oncology nurse navigator in tandem with the interpersonal care team, the patient and their family, using technology such as interactive video, audioconferencing, and telephone for communication.
Since navigators are well accustomed to care coordination, telenavigation has already been shown to improve care coordination with patients in remote areas, improve care team communication, address patients’ barriers to care and logistical challenges, and provide patients and families with education, survivorship care, and a high level of social-emotional support. All of these improvements are in addition to some of the more obvious benefits like convenience, flexibility, and safety.
Having seen the benefits and convenience of telehealth, patients are now asking for it, and with all of the new laws supporting telehealth, it is an ideal time for telenavigation to be incorporated into cancer care. Some providers argue that telenavigation represents the future of navigation and maintain that these appointments should become the standard of care if an in-person visit is not possible.
Navigating Mental Health and Cancer
The combination of a cancer diagnosis and depression worsens the cancer prognosis, but many depressed patients with cancer do not receive effective treatment, according to Kevin Scott Ferentz, MD, chairman of the Department of Family Medicine at Greater Baltimore Medical Center. Although treating depression in patients with cancer has not been shown to improve their survival (more research on this is sorely needed), it is still crucial that these patients receive appropriate treatment, as it can improve their quality of life.
Having cancer significantly increases a person’s risk for depression and anxiety: about 20% of patients with cancer will develop depression, and roughly 10% will have an anxiety disorder, but two-thirds of patients with depression also have significant anxiety symptoms.
Depression in patients with cancer most often presents during the acute treatment phase, but it can also present at diagnosis or discharge, during the survivorship phase, or at the end of life. It’s important to note that the incidence of depression varies widely according to diagnosis, from about 70% in pancreatic cancer to only about 6% in genitourinary cancers. This difference in incidence across malignancies may relate to prognosis, pain, or body image disruption. Patients who blame themselves for their cancer diagnosis (ie, smokers who develop lung cancer) are also more likely to become depressed. However, depression in patients receiving end-of-life care is no more prevalent than in patients living actively with their cancer.
Put simply, being depressed puts a patient with cancer at a higher risk of dying. Research has shown that a depression diagnosis and high levels of depressive symptoms in patients with cancer increased mortality; this was true whether the patient was depressed before or after their cancer diagnosis, and the association persisted after controlling for confounding medical variables. These findings underscore the importance of screening for and treating depression in patients with cancer. Patients can be screened for depression and anxiety through the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 Questionnaire, respectively.
Patients with cancer in the United States have nearly twice the incidence of suicide of the general population, and this risk varies according to the type of malignancy, with those having cancers of the lung, head and neck, testes, bladder, and Hodgkin lymphoma at highest risk of suicide. It’s important to ask depressed patients if they have thoughts of hurting or killing themselves. If a person is deemed to be actively suicidal, they should be accompanied until a psychiatrist with admitting privileges can intervene, and if the patient refuses, the police will bring them to an emergency department.
The prevalence of depression in patients with cancer is clearly higher than in the general population, but this is not entirely due to the stressors surrounding a cancer diagnosis and treatment. Proinflammatory cytokines (biomarkers of inflammation in patients with cancer) and certain cancer treatments can also increase the risk for depression. Additionally, some cancers themselves can release chemicals thought to cause depression (ie, elevated cytokine interleukin-6 in pancreatic cancer, paraneoplastic syndromes in lung cancer). Add to this the psychological reactions to diagnosis, as well as the many side effects patients experience, such as hair loss, sexual function, vomiting, mucositis and peripheral neuropathies, expectations regarding survival, and effects on work and social roles, and the higher prevalence of depression is clearly explained.
Most depressed patients will need pharmacologic interventions. While psychotherapy can be used as an adjunct to medication, it is not a replacement. According to Dr Ferentz, all antidepressants are equally effective assuming reasonable dosing, but before choosing a new antidepressant, any prior antidepressant use should be considered, including those used by family members.
In the largest meta-analysis of antidepressants to date, mirtazapine, escitalopram, venlafaxine, and sertraline were significantly more effective than duloxetine, fluoxetine, and paroxetine, and patients on escitalopram and sertraline had fewer discontinuations than those on duloxetine, paroxetine, and venlafaxine. Antidepressants can worsen existing cancer symptoms and interact with chemotherapy agents, but sertraline and citalopram tend to have the fewest interactions and are generally well tolerated as first-line agents.
Considering benefits, acceptability, and cost, sertraline (Zoloft) is generally agreed upon as the best first choice of antidepressant, barring any reasons for choosing an alternative (ie, many of a patient’s family members have done well on Prozac).
Not all patients improve on an antidepressant, and in these cases a second medication may need to be added. The most common drug used to augment an antidepressant is bupropion (Wellbutrin), but other options include buspirone, mirtazapine, topiramate, aripiprazole/brexpiprazole, and folic acid.
After a patient with cancer has been diagnosed with depression and prescribed an antidepressant, they should be seen by their healthcare provider within 2 weeks, and another PHQ-9 should be conducted. If the patient’s depressive symptoms have not improved in those 2 weeks, the dose should be increased; if there has been some improvement, they should be seen again in another few weeks and reevaluated; if there has been no change in the span of 4 to 6 weeks, they should discontinue that drug and try another antidepressant.
Unfortunately, the quality of the data on depression in patients with cancer is poor, and available studies are few and of low quality, so the choice of antidepressant should be based on data from the general population. However, treating depression in patients with cancer should always be practiced on a case-by-case basis, and the patient’s individual characteristics should be taken into account. Even though depression interventions do not appear to affect survival in patients with cancer, treating their depression can significantly increase their quality of life.
Prehab and Rehab for Oncology Patients
Rehabilitation and prehabilitation are critical to restoring an individual’s functioning after a cancer diagnosis. While barriers to the provision of prehab and rehab services exist, navigators can play an essential role in breaking down these barriers, according to Adrian Cristian, MD, MHCM, chief, Cancer Rehabilitation at the Miami Cancer Institute.
Rehabilitation medicine for patients with cancer serves 2 fundamental roles: maximizing a person’s level of function (physical, social, psychological, or vocational), and improving quality of life as defined by the individual with cancer (including returning to work or school, family life, and/or hobbies). The concept of oncological- functional integration is focused on maximizing and preserving the functioning of individuals going through cancer treatment throughout the entire care continuum.
The World Health Organization defines “function” as activities identified by the individual as essential to supporting physical, social, and psychological well-being. Cancer and its treatment can have a significantly adverse impact on a person’s level of function, and functional loss in cancer is often gradual and hard to detect at the very early stages.
Function and functional loss can be measured through the concepts of physical impairment (ie, muscle strength and sensory loss), activity limitation (what a person can no longer do as a result of those physical impairments), and participation restriction (whether at work, school, or in family and social roles).
Work is a fundamental aspect of life and is important for good physical and mental health, but cancer and its treatment can impact a person’s ability to work through side effects like physical symptoms, poor sleep, daytime fatigue, and decreased productivity. Only about two-thirds of cancer survivors return to work, and as many as 53% of survivors lose their job or quit working over the 6-year period following their diagnosis. However, rehabilitation medicine can improve a person’s ability to work by improving endurance and strength and minimizing physical impairments.
The goal of prehabilitation is to identify and treat any preexisting impairments in a patient and should be carried out in the time between diagnosis and the start of treatment. It also serves to reduce the incidence and severity of future impairments, and it is an ideal time to promote physical and psychological health.
Fundamentals of prehabilitation include nutritional counseling, anxiety reduction and smoking cessation as needed, as well as general exercise and identifying, assessing, and treating impairments early.
Rehabilitation can occur before, during, and after cancer treatment, as well as into the survivorship phase and advanced stages of cancer. Rehabilitation has been shown to be highly effective in reducing the impact of impairments and maximizing functioning, and it is also an ideal time to monitor patients for cancer-related impairments and loss of function.
One of the primary barriers to the utilization of rehabilitative services is a lack of access, as well as a lack of both caregiver and patient education about cancer-specific impairments and rehabilitative interventions. Additional barriers include geographic, work-related and health insurance–related restrictions, medical illness, responsibilities of child/parent care, and patients simply being “too busy” to attend medical appointments. Navigators can play a crucial role in addressing these barriers by identifying impairments early, as well as by advocating for patients to receive rehabilitative interventions.
Frailty is a common side effect of cancer and its treatment: about 42% of older patients are frail or prefrail. Frailty commonly leads to treatment complications (ie, intolerance to cancer treatment/intensity and postoperative complications), and is associated with increased all-cause mortality. Frail older adults are also less likely to complete their treatments due to amplified side effects, a decline in clinical status, increased toxicity, and frequent hospitalizations. Rehabilitative medicine can be used to identify those at risk of complications associated with frailty.
Impairments related to cancer and its treatment commonly occur in clusters. For example, a patient with breast cancer might have shoulder dysfunction, lymphedema, and peripheral neuropathy. Posttreatment, a person with head and neck cancer is at a significantly increased risk of aspiration pneumonia, an increased risk of psychosocial distress, and an increased risk of suicide that is 4 times that of the general population. These impairments can be detrimental to patients, so identifying them early—and intervening with rehabilitative medicine interventions—is crucial.
To identify functional limitations and impairments, navigators should ask patients certain questions, and these will vary according to malignancy. For example, in patients with head and neck cancer, navigators should ask about swallowing, mouth opening, neck swelling, shoulder problems, weight loss, and impact on work/social roles. Or, in patients with breast cancer, ask about shoulder pain/restricted movement, swelling of the arms, hand pain, nerve-related symptoms, memory loss, spine pain, weight gain, and impact on work/social roles.
Additionally, a simple screening method can be used in any clinical setting, and any patients with the following characteristics should be referred for cancer rehabilitation:
- Cannot raise their arm overhead to wave hello
- Cannot stand on 1 leg for 10 seconds
- Cannot get up out of a chair 10 times in 30 seconds
- Anyone who would benefit from a clinical trial but considered too frail to participate
- All stage IV patients
Value-Based Care and Alternative Payment Models
The state of oncology care has shifted away from a fee-for-service model and toward a value-based care model, and as a result, a number of alternative payment models (APMs) have been introduced. At their inception, the hope for APMs was a perfect alignment between the provider and the payer that ultimately benefits the patient in terms of their care delivery and overall journey, but the reality is, these models can be confusing and complex, and many providers are hesitant to take them on. Transforming a practice from a fee-for-service into a value-based model can be challenging, but understanding APMs is the first step toward making the change.
As APMs become more quality-driven, the financial risk to the provider also increases, so whereas these risk models do drive quality for patients, the provider must be ready to take on that higher risk.
Currently, 35 distinct oncology payment reform models are underway or planned in 37 states across the country; this goes to show that there is no one-size-fits-all model for every practice. Seven models operate in more than 1 state, and 4 are national: the Center for Medicare & Medicaid Innovation (CMMI) Oncology Care Model (OCM), Aetna, Cigna, and Humana. The implementation of clinical standards and measures are extremely important to APMs, particularly in terms of performance reporting and evaluation, as well as emergency department and inpatient admissions reporting.
Eighteen payment reform models offer shared savings (meaning any savings are shared with the provider) and/or include a management fee. Traditionally, payment reform models have been payer-based, but employer- driven models have doubled since 2019, and 4 of the 35 models are now employer-based.
Adding to the complexity of APMs in oncology are differing payment methodologies, differing methodologies used in calculating financial success, and differing practice transformation activities.
A total of 138 practices in 29 states are participating in the CMMI OCM, and this model serves as a benchmark for other APMs centered around total cost of care (all types of service; all diagnoses; no exceptions). The intent of the OCM is to drive up quality and lower cost by shifting from fee-for-service to value-based care, and it is driven by improving communication between providers and patients, recognizing depression and distress in patients with cancer, transforming care, addressing financial toxicity, and improving care coordination, symptom management, palliative care, and end-of-life care.
Within the OCM model, providers can still bill standard fee-for-service payments for all services rendered, and they also receive a $160 per member per month enhanced oncology services payment. This payment is intended to help fund the costs associated with practice transformation and any additional resources required in implementing the OCM model.
If a practice using the OCM model is successful and achieves savings, they will receive a performance-based payment based on a combined quality score. A score greater than 30% is eligible for a performance-based payment, but any score below 30% equates to no payment. Quality scores are based on the fulfillment of 12 quality metrics that fall under the 4 domains of communication and care coordination, person- and caregiver- centered experience and outcomes, clinical quality of care, and patient safety. The communication and care coordination score is based on claims data, while scores for person- and caregiver-centered experience and outcomes, clinical quality of care, and patient safety are all self-reported measures.
The measurement of success of an APM is based on 3 performance drivers that make up about 80% of spending: drugs, emergency department/inpatient, and end of life. While these 3 categories do inevitably account for substantial spending, practices should take certain steps to mitigate some of these costs, including using less expensive regimens (without compromising quality), using targeted interventions, having a formalized and consistent patient triage process, and improving end-of-life transitions and advance care planning by educating patients on palliative care and hospice.
If a practice wants to make the shift to an APM, 5 main components are required: gathering data, analyzing those data, care transformation (ie, effectively communicating all expectations and metrics to the care delivery team, focusing on patient engagement strategies), finances (ie, measuring quality-of-care activities as they relate to the overall cost of care delivery), and performance analysis (making sure the previous steps were carried out successfully, and what the practice is doing is actually working).
Oncology navigators can have a substantial impact on the process of identifying meaningful data sources, gathering data, making sure support exists from an IT and infrastructure standpoint, and developing consistent data-reporting methods. Importantly, they can also contribute to the element of data collection that is not technology-driven and that is gained from actual conversations with patients.
After data are gathered, they must be made actionable through data analysis. Benchmarks should be put in place, opportunities for performance improvement should be prioritized, and developing programs that will help a practice to achieve their quality metrics should be paramount.