Marsha DeVita, NPA
When nurses ask Marsha DeVita what it’s like to work at an oncology medical home, DeVita replies that it’s like working at an institution that nurses designed themselves.
That’s not to say that the medical home model eliminates the frustrations of traditional practice or that it lacks entirely new frustrations of its own, but DeVita and most of her colleagues believe in the model and take great satisfaction in two of its core elements: engaging more with patients and having more autonomy to implement standing orders for care.
“This model has rightly gotten a lot of attention by showing that it’s better for patients, but those gains don’t come at the expense of caregivers,” said DeVita, a nurse practitioner at Hematology Oncology Associates of Central New York.
“The model is better for nurses as well because it allows them to spend more of their time teaching patients and doing things that they wanted to do when they became nurses.”
Only a tiny percentage of the nation’s oncology nurses have any direct experience with the medical home model, but the numbers are likely to grow rapidly. The small number of oncology practices that have been operating as medical homes for several years now have significantly improved patient outcomes and reduced treatment costs, notes the Community Oncology Alliance. Several dozen more have opened recently or will open soon and—if they obtain similar results—the model could eventually become the standard for cancer care.
What Is an Oncology Medical Home?
To many who hear the term for the first time, an “oncology medical home” sounds like some sort of resident cancer clinic and, thus, a radical departure from a traditional outpatient cancer clinic.
In reality, it is more of an evolution than a revolution, an attempt to codify and spread best practices that researchers and clinicians have developed over the years. It is a "medical home” only in that it is the first place that all active patients learn to turn for all of their medical concerns.
The model requires that practices follow existing standards of care to the letter and that they thoroughly document their adherence to those standards. The first step ensures that comparable patients all get comparable treatment. The second increases the chance that payers will reimburse all work—and do so promptly.
The medical home model further requires that practices teach patients to identify potentially problematic symptoms early and, in most cases, to seek any necessary care from the practice rather than the emergency department.
These conceptually simple principles have considerable impact on nurses who move from traditional practices to oncology medical homes.
First, the effort to standardize care requires that nurses at medical homes gather far more information from each patient than they do at traditional practices. It also requires that nurses gather exactly the same information from each comparable patient, in exactly the same way, so that almost all of it can be entered into computer programs designed to help individual treatments match general standards.
The demand for detailed data extends far beyond a patient’s initial appointment. It colors nearly every interaction between patients and clinicians. Each time a patient calls on the phone or arrives for an appointment, clinicians must check a computer (or, sometimes, a printout) to see that they’re asking all the relevant questions, and they must enter the answers into the system.
This degree of standardization may not fill every nurse with joy. In fact, it may strike some as a new frustration that’s unique to the medical home model. It does, however, have its benefits.
For patients, the benefit is improved quality of care. Checklists help prevent clinicians from forgetting to ask important questions, and computerized data entry makes information easier to use over time.
For nurses, the benefit is autonomy. Nurses armed with huge amounts of patient data and standing orders about what data merits what response are free to proceed as their guidelines advise—without asking anyone’s permission.
Working the Triage Desk
Nurses have particular autonomy when they are undertaking one particularly novel aspect of the medical home model, the triage service. Many oncology practices have always let patients consult informally with nurses over the telephone, explaining their symptoms and getting the nurses to ask doctors whether they should come to the office or ride it out.
The medical home model expands upon the idea and makes it one of the cornerstones of patient care. Patients are given a list of potentially serious symptoms and repeatedly urged to call as soon as one arises. Nurses, meanwhile, are trained to deal systematically with every possible concern and assigned specially to the telephone triage desk.
The interactions, like all communications with patients, are strongly guided by algorithms designed to standardize care around best practices. Each practice develops its own algorithms, starting with guidelines from organizations such as the American Society of Clinical Oncology, and securing support from physician staff. It then uses them as structured guidelines, similar to standardized order sets for handling emergencies. Nurses open the record of each patient who calls and enter that patient’s initial complaints. The algorithm, which may be written into automated software or simply printed on paper, then helps to determine appropriate follow-up questions.
Every patient who calls to complain about symptoms X, Y, and Z will therefore be asked questions A, B, and C, and every patient who answers those questions in one particular way will be asked the same questions after that.
All this may sound antithetical to autonomy, but the system relies on nurses to correctly interpret patients’ answers as they try to express complex feelings that often defy expression and then—after all the information has been gathered and analyzed—to use their guidelines to suggest how care should progress.
Triage nurses determine whether patients should manage their own symptoms at home, come in for an appointment the same day or the following day, or go to the nearest emergency department.
“When nurses begin working the triage desk, they tend to run a fair percentage of their decisions past the doctors, but as they grow confident in their ability to use their tools to assist the decision process, they grow to enjoy their role in guiding care,” said Maureen Lowry, RN, BSN, OCN.
Lowry is director of clinical operations and process implementation at the first practice in the nation to implement the new model, the Oncology Patient Centered Medical Home in suburban Philadelphia.
“That’s not to say that everyone loves working the triage desk,” Lowry continued. “Some people enjoy it, and some find it difficult to assess a patient over the phone. It is definitely an art to dial into patient symptoms without seeing them physically, but by following the algorithms, nurses can streamline the assessment to gather all of the pertinent data needed to help the patient.”
“It’s rewarding and can be intense, and practices are still experimenting to find best practices on issues like whether they should rotate nurses onto and off of the triage desk or keep the same ones there all the time.”
Even now, when practices have yet to settle on an optimal way to staff their triage desks, the general idea of letting nurses, assisted by the algorithms, decide which people need care in which timeframe has paid dividends.
Most patients who call triage centers never need to see a professional, and most of those who do can visit their regular doctors.
Last year, the triage team at Lowry’s practice managed 86% of all patients who called over the phone—without any office visits—brought in 4% for same-day care, brought in another 3.4% for next-day care, and sent 2.4% to the emergency department.
Thanks largely to those efforts by the triage nurses, patients of the practice visited emergency rooms 70% less often than patients at traditional practices typically do. They were also admitted to hospitals 50% less frequently than normal.
Other practices designed around the medical home model have done nearly as well, according to research from the Community Oncology Alliance, which has helped to develop and promote the model. Cancer patients who use oncology medical homes consistently spend less time in emergency departments and hospitals in general than patients who go to traditional practices.
Basic Training at the First Visit
Triage is not the only reason for improved patient outcomes, of course. Supporters of the medical home model point to several other improvements over traditional practices, all of which affect the job that nurses do.
It starts with a patient’s first visit, when a nurse sits down with the patient to provide basic training. Cancer practices have always discussed the likely side effects and possible complications that come with treatment, but the medical home model goes much further. It provides patients with so much information that they, in effect, become their own initial source of diagnosis and care.
Nurses who work in oncology medical homes often spend an hour or more with patients during that initial consultation, explaining the diagnosis and treatment and then teaching patients what side effects are normal (though painful) and which signal possible danger.
Nurses teach patients the best way to deal with common side effects from their particular treatment regimens, how to evaluate whether they’re managing their own side effects adequately, when to call the triage desk and (on rare occasions) when to go straight to the hospital or call 911.
These training sessions, like nearly every aspect of medical home care, are largely scripted to ensure that care is standardized around best practices—not only in the sense of making the best recommendation for dealing with side effects, but also in using the best wording to explain the process of identifying and treating the symptom.
Still, effective communication inherently requires that people adapt to different situations, so nurses have broad responsibility to tailor messages to each audience and thus maximize each patient’s ability to cope with treatment. “People vary widely in their ability and desire to manage their own care,” said Carol Murtaugh, RN, OCN, cancer center practice administrator at Hematology & Oncology Consultants in Omaha, Nebraska.
“Yes, we are trying to standardize around best practices, but you would not give the exact same presentation to a lone 80-year-old with dementia as you would to a 50-year-old medical doctor who comes to the session accompanied by a spouse who is also in the medical field. Each patient has unique desires and unique capacities, and it is up to you to identify what those are and help each patient do the best job of self care that he or she is capable of.”
If all that sounds familiar to working nurses at traditional oncology practices, it should. Most of the duties for nurses who work under the new model bear great resemblance to most of the duties for nurses who work under older models. Ted Okon, executive director of COA, estimates that nearly every oncology practice in the country already adheres to about 80% of the guidelines for oncology medical homes.
“Cancer care has always been so intense that oncologists have been the primary care givers for people with cancer,” Okon said. “They have decades of experience in coordinating care with general practitioners and other specialists, so it’s natural that they evolve into true medical homes, generally one step at a time.
“Each of those steps comes with some challenges at first, but all of them produce tangible benefits and people soon adjust. For nurses, the overall effect is to increase the amount of time spent on patient care and to increase the quality of care they can give their patients, so it’s definitely a net positive.”
Reminding Patients—and Their Doctors
Another important aspect of the medical home model which affects how nurses work, is the emphasis on giving patients constant reminders to comply with standards of care.
Computer software can automatically perform much of the routine work, like e-mailing people to request that they make appointments and a day or 2 before those appointments, to remind them to show up. However, when those automated prompts fail to produce the desired behavior, the medical home staffers must step in to encourage patient compliance, and, at many practices, the staffers who do that work are nurses.
They call patients who miss appointments, help to schedule new ones, and impress upon them the potentially dire consequences of missing checkups. They contact people who fail to take medications on time and explain the vital necessity of using medication as prescribed. They call patients to check up on problems that those patients mentioned during routine visits, just to make sure those problems aren’t worsening.
In addition to checking up on patients to make sure they’re following best practices, nurses who work under the medical home model do exactly the same thing for doctors. This last task obviously requires considerable diplomacy. Nurses who are new to the model may struggle with it, but the medical home model demands that all clinically comparable patients receive the same treatment—a treatment that follows standards of care rather than the intuition of doctors, nurses, or any other caregivers.
In many cases, the agreements that medical homes have with payers demand that they document consistent adherence to standards, so all employees must enforce the rules, even if that means that nurses must sometimes “remind” doctors of what they “meant” to order or report with pretend frustration that the computer is “demanding” something other than what the doctor wants.
Indeed, “the computer” often deserves genuine blame for making frustrating demands. It drives work at medical homes far more than it does at traditional practices, and that creates both significant annoyances and significant benefits for people who work at such practices.
“The systems that these practices use require a lot of work from everyone. Every single bit of information on every single patient must go into the system, and very little of it can go in as unstructured text that you just type in a box. Nearly everything must be entered as structured information in exactly the right place,” said Amanda Hodges, BSN, RN, OCN, director of support services at The Center for Cancer and Blood Disorders in Fort Worth.
“It takes a huge amount of time to get everything in the right place, particularly when you are learning the system. That said, if you put in the work, the software can do some amazing things for you. It can make it easy to find every conceivable bit of information about a given patient. It can let you compare how things have changed over time with a single glance. It puts everything you need to make good decisions right in front of you, stuff you would never have had in one place before.”
“Yes, you’ll probably spend a lot of time cursing the system,” Hodges continued, “but ultimately it makes you better and ultimately that makes the job better . . . The whole system makes the job better.”