Cancer treatment can render the most capable 30-somethings unable to care for themselves, but it can take a far greater toll on older patients.

Chemotherapy can hasten physical and cognitive decline. Surgery can leave patients permanently weak. Even milder treatments that range from endocrine therapy to simple antihistamines can produce serious side effects.

Independent oncology practices cannot afford to address these challenges the way academic hospitals have, by hiring neurologists, dietitians, physical therapists, and other specialists. Nevertheless, nurses who work at smaller facilities can provide older patients with many of the same benefits.

“Even the largest of the specialty programs are executing a relatively simple idea: older patients undergo special assessments, and the results help to guide their treatment,” said Arti Hurria, MD, director of the Cancer and Aging Research Program at City of Hope in Duarte, California.

“Those big programs obviously have great resources at their disposal, but a few standardized assessments that are free online, combined with some operational flexibility and a willingness to refer patients to outside help, can often produce similar benefits.”

A patient’s chronological age matters less in “geriatric” oncology than the specialty’s name implies. Age does determine which patients undergo which assessments, but its importance fades thereafter. Calendar age correlates so imperfectly with individual decline that assessments are more informative than birth certificates.

A 75-year-old who runs a successful business clearly needs less cognitive support than a 75- year-old who forgets to get dressed. That said, experts warn, all elderly patients should be formally tested for age-related decline, no matter how functional they seem. People often hide their weaknesses, consciously and unconsciously, during ordinary interactions, but it is hard to fool a good assessment tool.

Such tools, moreover, are freely available online. Researchers have developed and validated a wide range of tests that provide large amounts of actionable information in small amounts of time.

Patients can perform some assessments entirely on their own simply by filling out questionnaires that gauge comorbid conditions, mood, eating habits, and physical abilities. This strategy is particularly efficient when practices let patients take their assessments on tablets or computers that send the answers directly into electronic health records (EHRs) and (in some cases) tabulate results automatically.

Initially, gerontologists worried about the reliability of this self-reported data, but studies have consistently shown that validated questionnaires hold up surprisingly well, even when compared with time-consuming performance evaluations that require third-party administration.

Among the best known of these tools is the 18-question Mini Nutritional Assessment (MNA) and its even briefer sibling, the six-question Mini Nutritional Assessment Short-Form, (MNASF). More than two dozen published studies have evaluated numerous aspects of the MNA in various settings over the past 20 years.

A review of those studies published in 2006 by the Journal of Nutrition, Health & Aging found that the tool had consistently demonstrated itself to be both accurate and easy to use in trials on more than 10,000 patients. Just 3 years later, the same journal printed a widely cited study that used data from more than 2000 patients to reach much the same conclusion about the newest version of the MNA-SF.

Research also has validated other assessments of individual aspects of patient health and functionality, but Hurria and her colleagues in the Cancer & Aging Research Group (CARG) have attempted to simplify matters by combining several validated tools into a single geriatric assessment that is largely self-administered. It is, of course, much longer than the MNA-SF. Indeed, its dozens of questions cover topics as diverse as losing weight, climbing stairs, driving automobiles, attending church, feeling depressed, maintaining relationships, and suffering ailments.

Still, older patients get through it with surprising speed. A 2011 study in the Journal of Clinical Oncology found that 87% of an 85-patient cohort (mean age 72) completed all of the questions, without help, in an average of just 22 minutes.

The many advantages of questionnaires might tempt time-strapped practices to omit objective tests entirely, but Hurria and other experts recommend that they resist the temptation. Indeed, the CARG assessment includes a couple of tests of basic physical and mental ability that caregivers must administer. Other popular options that provide similar information include the Mini Cog and the Timed Up and Go.

Such tests consume a surprisingly small amount of staff time. Timed Up and Go simply measures the number of seconds a person takes to get up from a chair, walk 10 feet, return to the chair, and sit back down. Even the Mini Cog has just 3 steps: (1) Read the patient three unrelated words and ask the patient to repeat them; (2) Ask the patient to draw an analog clock reading 11:10 or 8:20 on a blank circle; (3) Ask the patient to recall the three words.

How much information can such simple tests reveal? Studies show that the first is an accurate predictor of fall risk, whereas the second is an accurate detector of cognitive impairment. All told, at practices that administer questionnaires electronically and use software to score results, it might take an experienced nurse 15 minutes to gather and review the information from all the tests discussed above. And, another 15 minutes of informal observation can provide a wealth of extra insight.

“Assessing the older patient beyond standard oncology management is critical to the clinical picture. Selecting appropriate assessment instruments can help construct a reasonable cancer care strategy,” said Janine Overcash, PhD, GNP-BC, associate professor at Ohio State University College of Nursing.

“Of course, assessing a patient’s condition is the easy part. The harder and more time-consuming part is responding appropriately when those tests reveal problems. You need to decide how you’re going to handle whatever issues you find, and then you need to carry out whatever plan you make.”

For nurses, good response planning starts with a procedure for communicating relevant assessment results to oncologists and other specialists.

Granted, oncologists already have many other tools to help them match individual treatments with individual patients, including patients with age-related morbidities. Still, the data that nurses gather from age-related assessments and personal observations provide a valuable addition that can sometimes change treatment decisions.

Patients with signs of dementia, for example, will not reliably comply with treatment plans that require them to do much more than take a fixed number of pills at a single set time each day. A particularly frail patient, on the other hand, will often fare worse on chemotherapy than hardier ones.

Nurses themselves can do even more with the data they gather. Indeed, the results will often indicate that patients have greater needs than nurses can address on their own.

Oncology nurses can give tips for maximizing calorie intake to patients who struggle to eat enough during chemotherapy. However, when complete diet programs are required for patients who suffer malnutrition at baseline, that’s a job for a dietitian. When meals need to be prepared for patients who lack the strength and energy to make them on their own, social workers and family members can provide support.

Similar logic applies in many areas. Nurses should try to help patients who get a little blue during chemotherapy; psychiatrists should try to help patients who suffer from clinical depression. Nurses should encourage fundamentally fit patients to keep (somewhat) active during treatment; physical therapists should try to improve functionality in frail patients. Nurses should advise people with borderline blood pressure to walk a little more and ease up on the salt; internists should treat the sort of severe hypertension that can hinder cancer treatment and trigger strokes.

Proper assessment of older patients will reveal that many need all sorts of specialty help. Some will need social workers to keep their houses in order or provide guidance on finances. Some patients will need medical alert systems, regular visiting nurses and, in some cases, a place at an assisted living facility.

Specialty help not only improves overall patient welfare, but also improves oncology outcomes. Depressed, malnourished patients lack the physical and mental strength to recover properly from cancer treatment. Each practice should compile a list of well-regarded providers of services senior patients might require when assessments demonstrate a particular need.

Of course, many patients will never make any appointments because their problems prevent them from exerting the necessary effort, even when they start off with contact information. A better policy, therefore, might be to actually set up appointments for patients who consent to such help.

This policy has obvious benefits for patients, but experts say it can also benefit oncology practices. If, for example, you try to make appointments with providers who use the same EHR you use, then you will have easy access to records that can help your treatment decisions (assuming your patients allow it). Even if sharing isn’t always seamless, standing relationships facilitate communication and promote success.

Better still, when patients get all the supplementary help they need, they often need much less special attention from oncology nurses. Physical therapy increases strength and improves balance. Better nutrition increases both patients’ energy levels and their ability to concentrate.

Age-related impairment slows both mind and body, so nurses (and schedulers) need to allot more time for every aspect of every visit: a walk down the hall, a change of clothes, a trip to the bathroom, and a simple discussion. They also need to modify their normal techniques for communicating complex information.

Older patients, even those who suffer no cognitive impairment, tend to process information relatively slowly and forget it relatively easily. Nurses should counter this by speaking at a more deliberate pace, cutting information into small nuggets, writing those nuggets out for later study and suggesting websites that provide reliable supplemental information. (The idea that seniors struggle online is outdated, gerontologists say. Today’s seniors were middle-aged when the Internet became popular, and they often spend more time online than younger patients.) The key to minimizing the extra time requirements is thinking things out in advance.

“Little things like giving people who walk slowly the examining rooms nearest the waiting room, advising unsteady patients about which footwear minimizes fall risk, or positioning the people who will need the bathroom most in the chair that’s next to the bathroom—they all add up,” said Lorraine K. McEvoy, DNP, MSN a nurse leader in the geriatrics program at Memorial Sloan Kettering Cancer Center.

McEvoy believes practices should work particularly hard to minimize walking distances for geriatric patients who undergo chemotherapy. Such efforts do more than save time. They increase patient safety.

“One significant challenge of geriatric oncology is awareness of how the necessary premedication drugs should be dosed to adequately prepare the older adult for a particular regimen of chemotherapy,” she said. “Seniors tend to experience adverse reactions to many of the medications that are typically used, but there’s usually no way to omit those medications altogether and still give the chemotherapy. The challenge, therefore, is to determine what dose of each medication provides the optimal balance of effect and side effect.

“Even when you find the right dose,” she continued, “side effects can occur, so you need to watch senior patients far more carefully. For example, an older adult should never get up from a chemo chair without help from someone. You just need to commit yourself to the extra effort, or eventually you’re going to be dealing with falls and broken bones and hospitalizations.” As geriatric patients move through their course of treatment, nurses need to keep a particular eye out for signs of decline.

Here, again, the initial assessments prove beneficial, in this case because they provide an objective basis for measurement. Without baseline tests, nurses might not recognize if a particular patient’s gait is deteriorating. Having a clear understanding of where the patient was prior to the start of treatment enables the clinician to recognize subtle alterations in the patient’s status.

This is important for at least two reasons. First, cancer treatments (especially chemotherapy) are often far more toxic in older patients than younger ones and can do substantial permanent damage if problems are not caught early. Tests that demonstrate a patient’s gait has gotten worse are important because they signal a need to check whether it is the neurotoxicity of the treatments that has caused the problem.

Second, declines that put geriatric patients at risk of falling are particularly dangerous and demand countermeasures. Falls produce broken bones, which can lead to hospitalizations and (in a surprising number of cases) permanent decline.

Geriatric care would benefit patients with cancer significantly if it did nothing more than prevent a fair number of those debilitating missteps, and even basic geriatric care can improve outcomes. Yet, the one thing it doesn’t improve is the bottom line.

“There’s almost no way for an oncology practice to bill for any extra service they provide to geriatric patients, so all their pains generally won’t produce an extra nickel of revenue,” said Hyman B. Muss, MD, a professor at the UNC-Chapel Hill School of Medicine who helped build the geriatric oncology program at the university’s Lineberger Cancer Center.

“There are those who believe that may change if we move far enough from fee-for-service to fee-for-outcome, because good geriatric care certainly improves outcomes. If that is to happen, though, it will require payers to give practices the same amount of money to treat fewer patients, and it will be hard to make that fly, even if it does improve outcomes.”

“Fortunately, it is possible to do the basics efficiently enough to avoid bankrupting your practice, but you will still be sacrificing some amount of profit to help patients do better. It’s a labor of love.”

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Optimizing Geriatric Cancer Care Calls for Careful Assessment, Clinical Awareness

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&mdash;the model could eventually become the standard for cancer care.

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.

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&mdash;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&mdash;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.

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.”

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.

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.

Andrew D. Smith

Articles

Optimizing Geriatric Cancer Care Calls for Careful Assessment, Clinical Awareness

Oncology Medical Homes: An Expanded Role for Nurses Offering Benefits-and Challenges