Adding More Care Into Cancer Care

As the continuum of cancer care grows, more hospitals are going the extra mile for their patients.

This article first appeared in the November 2016 issue of HealthLeaders magazine.

It doesn't matter that the care is good if the caring doesn't happen," says George Raptis, MD, acting executive director of Northwell Health Cancer Institute, which encompasses cancer services throughout 21 hospitals and approximately 500 ambulatory sites in metropolitan New York.

"We have to do more for our patients than care for them," he says. "They spend their frequent flyer miles. They spend significant time waiting to see us. They spend significant time getting treatment. And on a humane level, we need to do more than have them stare at the wall. We have to make them feel better."

While making patients feel better includes helping them manage symptoms of disease and side effects of treatment, that's not all. Northwell, like a growing number of organizations, has also embedded an array of nontraditional support services into its oncology service line, aimed to help guide patients with cancer and their families through the entire continuum of care.

"You cannot provide chemotherapy alone," says Raptis, who specializes in breast oncology.

"If a person doesn't have easy access to rehab medicine for decreased range of motion, those patients are going to walk around with arms that are stiff and painful or be on pain medicines that have side effects," he explains.

"If I don't ask if they're having financial toxicity, then they're going to be anxious and they're not going to get the care they need."

To address these needs, more hospitals are providing patients access to financial counseling, social workers, support groups, palliative care, wig banks, music therapy, art therapy, massage, reflexology, and more.

Making the business case to provide these extra services isn't always easy, but Raptis and others insist that approaching cancer care holistically helps build patient loyalty, boosts clinician resilience, and is conducive to better clinical outcomes.

"Do I want more for these patients?" Raptis asks. "Yes. Would I do much more if I had the resources? Absolutely. How am I planning on doing that? Each year I push the bar a little further, and to do that I have to show that our financial performance as a service line is good."

Success key No. 1: Rethink care teams
For Lancaster (Pennsylvania) General Health/Penn Medicine, a 631-licensed-bed nonprofit health system with a comprehensive network of care encompassing Lancaster General Hospital and Women & Babies Hospital as well as a 300-member physician practice, an enhanced focus on patient-centered supportive care began with the opening of a new cancer center in July 2013, according to Randall Oyer, MD, medical director of the oncology program at Lancaster General's Ann B. Barshinger Cancer Institute.

"We wanted to make sure that the new cancer center wasn't just a building and wasn't just the same work moved into a different location," he says. "We began to change our care model so that the new cancer center was meaningful to patients, meaningful to staff to amplify their work, and would provide the opportunity for us to work with our community to support its needs."

The organization's first step toward these goals was to build a supportive care team, which focused on providing patients with emotional, spiritual, and nutritional support.

"We made our social worker, our chaplain, and our first oncology dietitian our support care team—and that did a number of things," Oyer says. "One, it began to shine the focus on patient support beyond medical chemotherapy and radiation. Two, it began to develop a core support team. And three, it brought new thinking to the table to ask, 'What are the gaps? Who else should be part of this care team?' "

To that end, the team grew to include behavioral health professionals, physical therapists, and financial counselors.

These individuals are organized into "disease teams," working together to take care of patients with, for example, lung cancer or breast cancer, Oyer explains. "It's not a nutrition department and a radiation department, but disease teams that create the handouts and the synergy that our patients need."

It's not uncommon for patients' treatment to be undermined by transportation problems or psychosocial barriers, both of which can impact patient outcomes, says Alon Weizer, MD, ambulatory care unit medical director of the University of Michigan Comprehensive Cancer Center. The center is part of UM Hospitals and Health Centers, and patients can meet with multidisciplinary teams in one of 17 multidisciplinary and 10 specialty clinics, organized by cancer type. In 2015, the center conducted 97,147 outpatient visits, 58,419 infusion treatments, and 4,590 radiation consults.

In the days before patient navigators, counselors, and others entered the oncology scene, patients' nonmedical challenges often went unaddressed, creating frustration for patients and oncologists.

"In the past, you had the physician at the top and it was a bit like a pyramid, where the physician would handle everything or be the one to delegate responsibilities to the rest of the team. I view that pyramid as flattening at this point," Weizer says. "We have a whole team of people who bring particular expertise, and it makes the actual healthcare delivery easier because it allows every individual that participates in the healthcare team to function at their highest capability."

Now, rather than having to manage crises on the back end, the team can problem-solve proactively. "If we know up front that travel is going to be an issue, a lot of times the navigator will address that even before the patient comes to clinic," he says.

Success key No. 2: Connect with your community
Even outside of the exam room UM's patient support services are expansive, including counseling, support groups, complementary therapies, a survivorship program, and numerous other resources and amenities. As with other organizations, these programs are funded largely by donations.

"Much of this is heavily dependent on philanthropic support and so there's a lot of effort within the cancer center to maintain that generosity," Weizer says. "But at the same time, there are many people willing to donate and support these efforts because they know that patients and families derive a lot of meaning from the work."

Oyer notes that the United Auxiliary of his hospital continued its 75-year tradition of supporting community needs by participating in the cancer center's supportive care and survivorship programs, both in terms of helping to outline the model of care and provide financial support with a $1.5 million endowment.

Likewise, in addition to the funds budgeted and donated for Northwell's support programs, volunteerism and creativity go a long way, says Raptis. "It's a little bit of shared cost for everyone, but in the end we don't look at things we do in silos. Quite frankly, if you take good care of patients it is good business. It's our mission."

Success key No. 3: Play the long game for ROI
In the long run, investing time, energy, and dollars into supportive care benefits patients and caregivers, says Penelope Damaskos, director of social work at Memorial Sloan Kettering Cancer Center in New York City, a private cancer center, treating more than 400 different subtypes of cancer each year.

The center offers individual and family counseling, numerous support groups, spiritual and religious care, and art and music therapy programs.

"We work from a strength-based perspective to help patients identify the strengths not only within their own coping repertoire but also in their families and communities," she says. "And we help them activate those strengths so that it helps them move through the cancer treatment trajectory much more quickly and effectively."

It will remain to be seen, however, whether that theory holds in an increasingly risk-based environment, says Weizer, whose cancer center is participating in Medicare's Oncology Care Model, a five-year bundled-payment pilot that began on July 1.

Lancaster Cancer Center, Lancaster General Health Physicians Hematology & Medical Oncology, and Lancaster Hematology Oncology Care are also among nearly 200 nationwide participants.

"The way we've thought about complementary therapies and family support services from a bundled-payment perspective is that, yes, if we can proactively identify barriers that patients have to care, fundamentally that should reduce or diminish any delays that people have with their treatment, which ultimately should result in better outcomes," Weizer says.

And even if the extras for patients and families don't augment organizations' bottom lines now, chances are they will.

"You have to play the long game," Weizer says. "The ROI might not necessarily make sense in the short term, but I think for the way care is going to be delivered in the future, we all need to be guided by what's the right thing for the patient to have the best outcomes and for us to reduce the morbidity and, frankly, improve the value of the care."

Healthcare organizations must also be mindful of not providing patients any gift or service that may be construed as an inducement to Medicare beneficiaries. For example, Medicare regulations preclude organizations from giving beneficiaries free transportation, Oyer notes.

"While the Oncology Care Model does give us the opportunity to be more creative and requires a complement of services, we are always cognizant of, and compliant with, Medicare regulations," he says. "We view the complement of supportive services provided by Lancaster General as a cancer patient's Bill of Rights. We employ professional specialists to provide chaplaincy, financial counseling, nutrition, and social work services free of charge. These services are provided to patients who are receiving cancer care at Lancaster General in compliance with standards from the American College of Surgeons, which is the accrediting body for Lancaster General's cancer program."

Success key No. 4: Emphasize survivorship
Speaking of longevity, more people are surviving cancer than ever before, with a record 15.5 million U.S. survivors in 2016, reported by the American Cancer Society, and it predicts they'll total more than 20 million in another decade.

But remission does not mean a person's cancer journey is over.

"The posttreatment phase, we realize now, is a distinct phase of cancer treatment and can represent another sort of unexpected crisis for patients," says Sloan Kettering's Damaskos. "More and more people are living with cancer as a chronic disease, so it's widened the continuum of care."

Oncology social workers, through individual and group counseling, can help patients who've completed treatment cope with feeling "out of sync" with their peers, who are experiencing hypervigilance, or are anxious about an uncertain future, she says.

Formal survivorship programs can not only help patients navigate postcancer chapters but celebrate them as well.

Northwell, for example, gathered nearly 2,000 cancer survivors and their families at its 10th annual Don Monti Cancer Survivors Day held in June.

"It's the happiest day here for all of us," Raptis says. "And the patients love it. They feel we're doing something very special for them—and we are—but it's also special for the faculty and staff."

Staff involvement in survivorship is invaluable, says Damaskos. "They're dealing with acuity all the time. So to be able to work with people who are post-treatment, they can see the other side or another perspective and see their patients thriving in many instances," she says.