Julie Silver, MD
As the clock ticks closer to the January 1, 2015 deadline for the implementation of the new Commission on Cancer (CoC) standards, I’ve been asking nurses and patient navigators this question: What are you going to focus on come January 2, 2015 and beyond? What’s next?
I have asked this at many of my lectures to nurses, and typically a hush comes over the room. The audience looks surprised and sometimes a bit confused. Why isn’t she talking about what everyone else is talking about—the new standards? Is she really asking us to look ahead and plan to take on more challenges and responsibilities when we’re already overwhelmed with 3.1, 3.2, and 3.3? (Box
) Can’t we have a break—a year or 6 months at least—before having to think about what comes next?
I founded the STAR Program (Survivorship Training and Rehabilitation), a model of evidence-based cancer rehabilitation for hospitals and cancer centers which want to meet (and even exceed) CoC Eligibility Requirement 11 (E11): Cancer Rehabilitation. These programs involve multidisciplinary teams of clinicians, including nurses, who work with patients on personalized recovery plans targeted to their treatment-related impairments. E11 is not a new standard, though many people think it is. Perhaps this is because the three newest standards, especially 3.1-3.3, are designed to help increase cancer rehabilitation referrals, so every survivor who needs services will receive them.
New CoC Patient-Centered Care Standards:
3.1--A patient navigation process to address healthcare disparities and barriers to care
3.2--Screening patients for psychosocial distress
3.3--Survivorship care plans that document care received and follow up care
The STAR Program was created so that rehabilitation could become the standard of care in oncology, in the same way rehabilitation is the standard of care in orthopedics, stroke, etc. At the recent STAR Program Connection Conference, I gave a talk which highlighted strategies for guiding and supporting our programs in 2015: “Engage and support your nurses” was number one on the list.
Achieving Triple Aim
This strategy isn’t intended to address oncology nurse burnout, but rather to enable our programs to more effectively achieve the Triple Aim
—an initiative developed by the Institute for Healthcare Improvement that focuses on improving patient satisfaction and health outcomes while lowering healthcare costs. Nurses are integral to oncology service lines (which should include cancer rehabilitation).
While the new CoC standards are an excellent springboard to achieving the Triple Aim, current research (and common sense) tells us that none of them—whether implemented individually or together—are likely to accomplish all of the Triple Aim goals. For example, it is unlikely that survivorship care plans will achieve the Triple Aim (remember that a major component of the survivorship care plan is the documentation of services delivered). For instance, if a woman with breast cancer has a mastectomy and subsequent shoulder problems that are not rehabilitated, then she may end up with a metastatic work-up that investigates nonmalignant pain (this is a fairly classic case—untreated impairments that cause pain on the affected side often result in a metastatic work-up that turns out to be negative). This means she has more pain and disability than is necessary and a lower quality of life. And the cost of the metastatic work-up may be more than the cost to rehabilitate her. In a survivorship care plan, all of this would be documented—but it contradicts the Triple Aim’s objectives.
Similarly, scientific evidence to date does not suggest that distress screening by itself will support the Triple Aim. In fact, identifying distress in cancer patients is likely to increase healthcare costs with the screening process and subsequent referrals to mental health and other psychosocial services—most of which will not significantly impact physical health outcomes (key to the Triple Aim).
Current studies show that physical impairments (or disability) are a leading cause of distress in survivors. Therefore, there is a major disconnect between the clinical practice of distress screening alone and the scientific literature, which suggests that identifying physical impairments (and treating them) is what will have a bigger impact on the Triple Aim.
“Engage and Support Your Nurses”
The navigation standard 3.1 has great potential as a springboard for accomplishing the Triple Aim. Although this standard refers to a navigation process
, for the purpose of this essay, let’s focus on nurse navigators. Engage and support your nurses
is a key strategy for all STAR Programs going forward because nurse navigators are uniquely positioned to help our multidisciplinary teams achieve the Triple Aim.
Navigators will need to implement and track very strategic initiatives, however, that demonstrate their value. This includes dual screening with appropriate early referrals to cancer rehabilitation (treating physical impairments early will improve outcomes, make patients much happier, and keep costs low). This also includes prehabilitation—which is not the same as nurse-led education. Prehabilitation involves conducting assessments that include numbers—these, in turn, can be converted to charts and must demonstrate specific outcomes (not only of individual patients, but also of an oncology population—consistent with the Triple Aim objectives). Prehab will require nurses to develop new clinical competencies in rehabilitation medicine.
Consider what is happening at your institution now. What’s next? How are you going to use these new patient-centered care standards as a springboard to achieving the Triple Aim in your oncology work? We all need to focus on reducing healthcare costs while simultaneously improving patient satisfaction and health outcomes. Going forward, this will be the measure of the quality and value of oncology care. All cancer centers need to develop comprehensive survivorship programs that provide patients with the best possible health outcomes, and nurses are ideal candidates to support, and often even lead, these initiatives.
Julie Silver, MD is a founder of Oncology Rehab Partners, which developed the STAR Program Certification, a service-line model for high-quality cancer rehabilitation care that has been adopted by more than 200 hospitals and cancer centers.