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APP-driven oncology urgent care can improve patient satisfaction, quality of life
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Editor’s note: HemOnc Today’s columns for advanced practice providers (APPs) tackle common issues APPs face, discuss day-to-day practice and regulatory concerns, and share research advances. To contribute to this column, contact Alexandra Todak at stodak@healio.com.
Oncology care has shifted to a predominantly ambulatory setting, which has increased the volume of urgent same-day visits for disease and treatment-related effects. This has led to high utilization of the ED and subsequent admissions.
At Smilow Cancer Hospital — which is affiliated with Yale New Haven Hospital and Yale Cancer Center and is one of 41 NCI-designated cancer centers and a member of the National Comprehensive Cancer Network — we sought to utilize APPs’ expertise to reduce ED usage and hospitalization among patients with cancer. With radiation therapy services, a women’s cancer center, a stem cell transplantation/chimeric antigen receptor T-cell therapy program, palliative care/hospice services, a cancer survivorship program, integrative medicine services, and 10 Smilow Care Centers throughout Connecticut, our patients present with a multitude of complexities that require specialized care.
Implementation of same-day visits
In 2014, we analyzed ED utilization and hospital admissions in a 5-month period, from Jan. 1 through May 31. In total, 391 oncology patients presented to the ED and 90% were admitted to the hospital, with a mean length of stay of 6.74 days and daily health care cost of $1,838.
Most patients (62%) were seen during the daytime hours and about 50% could have been treated in an ambulatory setting.
Common admitting diagnoses included fever, abdominal pain, altered mental status, dehydration/electrolyte imbalances and dyspnea.
Based on these data, we implemented a pilot program for APP same-day visits, and our APP Priority Visit program was developed secondary to the above data analysis.
We set up a task force — comprised of APPs, nurse coordinators and practice nurses — to determine current practices among disease teams. The task force evaluated practices and established guidelines for an urgent visit program and its implementation.
The same-day visit program had access to urgent palliative care consultation, pharmacy and infusion chairs. Patient/family member calls are escalated to practice nurses and/or APPs, and our urgent visit hours were 7:30 a.m. to 3:30 p.m.
The plan of care is established after the patient is evaluated and after considering whether they could be managed as an outpatient and discharged, whether they should be directly admitted, or whether they require a higher level of care and should be directed to the ED. To keep track of priority/urgent visits, we developed a visit type in our electronic health record system called “priority visit” for data-tracking purposes.
In the first 8 months, the APPs saw 687 patients with a mean of 20 patients per week. Overall, 113 patients (16.4%) were directly admitted and 15 patients (2.2%) were transferred to the ED for higher-level care.
These data reveal that most of the patients — 81.4% — were discharged to home with appropriate interventions and follow-up. This initiative showed that urgent visits could reduce ED utilization and subsequent hospital admission with reduction in health care costs, increased patient satisfaction and improved quality of life.
Meeting staffing demands
Despite the benefits of the program, it was constrained by APP staffing and operation hours.
This led to the development of a business plan and opening of the Oncology Extended Care Clinic (OECC) in April 2017, consistent with the Oncology Care Management (OCM) Model.
The clinic is open 7 days a week, from 7 a.m. to 11:30 p.m., and staffed with four full-time APPs and the support of two supervising physicians. The complement of APP experience includes oncology and emergency care. The unit has capacity for six patients.
The providers make referrals to OECC and they are triaged for appropriateness. Patients are treated as priority patients — similar to ED patients — with radiology, laboratory, pharmacy, rapid response team and referrals to specialty consult services.
Our data are analyzed every month and include number of patients seen, number of patients discharged, number of patients admitted, number of patients seen by disease team first, distribution of visits by day and arrival time, chief complaint/discharge diagnosis, and referring disease team.
During our first year — April 3, 2017, to March 31, 2018 — there were 2,634 patient visits. Sixty-nine percent of patients were discharged to home and the remaining patients were admitted. The three top referring disease teams are hematology, gastrointestinal medical oncology and thoracic medical oncology.
The data over the past year have remained stable. Our roll-up data for the past 2 years — through March 31 of this year — revealed 5,584 patient visits. Sixty-nine percent were discharged to home and the remaining patients were admitted.
Urgent need for urgent care
APP urgent care has provided our patients with the opportunity to access urgent care outside of the ED, leading to reduction in hospital admissions and enhanced patient experience and overall satisfaction, as evidenced by Press Ganey survey results.
After 2 years, we have developed staffing and triage guidelines and are currently developing oncology urgent care treatment algorithms with ongoing data analysis for ED utilization, cost-effectiveness and patient satisfaction.
Oncology-specific urgent care has gained much interest and attention over the past several years. With the acuity and complexity of disease — and treatment-related effects in the oncology patient — their care should be provided by staff that have oncology expertise. Much of their management is centered around disease progression; symptom management, including pain control; and treatment effects, such as neutropenia and immunotherapy-related effects.
One of the goals of oncology care is to provide exceptional care while reducing suffering and improving quality of life. Hospitalizations can have a negative impact on quality of life, especially for those nearing the end of life. Designated urgent oncology care can help to avoid that as well as improve patient/caregiver satisfaction and experience.
For more information:
Vanna M. Dest, MSN, APRN-BC, AOCN, is senior program manager of oncology APPs and is oncology APRN of head/neck and thoracic medical oncology and at the Oncology Extended Care Clinic. She can be reached at Smilow Cancer Hospital, 20 York St., New Haven, CT 06510; email: vanna.dest@ynhh.org.
Disclosure: Dest reports no relevant financial disclosures.