Primary care finds a home within cancer center
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Click here to read the related commentary, “Can oncology rescue primary care?”
When Nicholas J. Petrelli, MD, FACS, learned that many patients at the Helen F. Graham Cancer Center & Research Institute lacked a primary care clinician, he knew something needed to be done.
Source: Helen F. Graham Cancer Center & Research Institute at ChristianaCare.
“We discovered serendipitously, in talking with our gynecologic oncology surgeons, that about 15% or so of our gynecologic oncology patients didn’t have a primary care provider,” Petrelli, Bank of America endowed medical director of the cancer center and associate director of translational research at The Wistar Cancer Institute, as well as a HemOnc Today Editorial Board member, said in an interview with Healio | HemOnc Today. “Because primary care providers are still the gatekeepers for cancer and because cancer has turned into a chronic disease with increasing comorbidities, I thought, ‘Why don’t we put a primary care physician in our cancer center?’”
That idea was the first step toward the introduction last year of a primary care practice at the center, which is part of the ChristianaCare health system. Since then, the model earned Graham Cancer Center a 2022 Association of Community Cancer Centers Innovator Award for demonstrating benefits such as improved patient care coordination and reductions in patient stress levels and treatment delays.
As of July 22, 207 patients have been referred to the primary care practice, with a 90% patient satisfaction score, according to data provided by the center.
“Patients are so grateful to be able to come here,” Debra Delaney, MSN, RN, ACNS-BC, FNP-BC, a nurse practitioner who serves as a primary care provider at the center, said in an interview with Healio | HemOnc Today. “The cancer center has been very generous with my time. I’m allotted enough time to sit with my patient, get to know them and talk to them. It’s really been a wonderful experience. I can’t believe this is a novel idea. It should be done everywhere.”
‘We had to let people know’
The primary care practice expands on the Wilmington, Delaware-based center’s Oncology Express Unit, a pilot program that offers urgent care to patients with cancer during active treatment. Housed in the same location as the Oncology Express Unit, the primary care practice sees patients who do not have their own primary care clinician and addresses nonurgent concerns.
“The whole idea of the cancer center is to keep patients in the center for whatever care they need,” Petrelli said. “Primary care is an important part of the multidisciplinary team, so we decided we needed to offer it at the cancer center.”
When establishing the program, Petrelli said he and his colleagues decided that their primary care provider did not necessarily need to be a physician.
“Our former chair of radiation oncology, who is now a quality and safety officer, said, ‘Why not start with an advanced practice provider?’ That’s what we advertised for, and that’s when Debra showed up. Quite a few people knew her and spoke highly of her.”
One of the biggest challenges in implementing the program was simply making people aware of its existence, Petrelli said.
“I spoke to a couple of colleagues across the country, and none of them had experience with primary care in a cancer center,” he said. “So, we had to let people know.”
Even many clinicians at Graham Cancer Center did not know about the new primary care practice, according to Petrelli, who said he, Delaney and others had to “market” the program to physicians in several oncologic disciplines.
“Our oncologists are very busy treating patients’ cancer, and they might not take the time to remember that we have a primary care practice in the cancer center,” he said. “Communicating this to everyone took a lot of time. It was a barrier, because these are busy physicians.”
‘An extra pair of hands’
Delaney said her role comes into play when a patient at Graham Cancer Center reveals they do not have a primary care provider. These patients might be dealing with long-term comorbidities such as hypertension or diabetes. Because their cancer treatment is often extensive and time-consuming, Delaney said she is happy to be able to provide primary care while sparing the patient the travel time involved in seeing an outside provider.
“Because I am here in the cancer center, their oncologists can send a referral and I can do an evaluation, check their background and see what medications they are on,” she said. “I can offer them all of the usual services that primary care provides.”
Delaney said when patients are first diagnosed, she tries to help them navigate the many lengthy and potentially confusing conversations they will likely have with various specialists, including psychologists, nutritionists, pain management specialists and surgeons.
“In the beginning, when there is a new diagnosis of cancer, patients are overwhelmed and they’re scared, and they’re given a lot of information,” she said. “This is the busiest patient population I have ever dealt with. They have so many people talking to them. They meet with physicians in many different disciplines.”
During her appointments with these patients, Delaney helps them process the information they’ve received and further determine what types of multidisciplinary care they might need.
“I can ask them if they feel comfortable with their plan, and I can help them through referrals to our other services,” she said. “I talk to them about making good food choices during treatment, and the importance of hydration. If I see someone struggling emotionally, I can reach out to psychology and say, ‘I have someone I think would benefit from your services.’ I am an extra pair of hands for everyone.”
Monitoring for adverse effects
During the primary care appointment, Delaney and her patients also discuss any contraindications or drug-drug interactions and other concerns patients might have regarding their cancer treatment.
Petrelli pointed out that one crucial job of the primary care clinician treating a patient undergoing active cancer treatment is to be aware of the potential complications of the various anticancer medications.
“One of the most important things is knowing the side effects of the medications,” Petrelli said. “So, if a patient comes in with high blood sugar, it might not be adult-onset diabetes, it might be the agent they are on for cancer treatment.”
Delaney makes herself available to patients in between their appointments and makes follow-up calls in some cases.
“My patients are excellent at keeping in contact with me, because I tell them I’d rather know about it now than find out about it later,” Delaney said. “I push that very much, because a side effect like diarrhea, which is common, can cause them to get behind the 8-ball with their fluids and can lead to dehydration. We need to make sure they’re hydrated and getting their nutrition.”
Once her patients have finished their cancer treatment at Graham Cancer Center, Delaney said she helps them establish primary care at a practice outside the cancer center.
“We want to coordinate their care and keep them healthy,” she said.
A potential fellowship
Delaney said although she had limited oncology knowledge when she joined the cancer center, she has learned a great deal from various specialists there, as well as from being on the job.
“The oncologists have been fabulous, as well as the surgeons, other physicians and the advanced practice providers,” she said, “We work together because we’re a community and we’re working for the patients. We’re ‘all for one.’ When I reach out with a question, they help me understand. Then I look it up and start to investigate on my own and read more. I’m teaching myself, as well as learning from all the disciplines.”
Petrelli praised Delaney’s pursuit of oncology knowledge and said it is essential that PCPs and advanced practice providers receive education on the various effects of cancer and its treatment.
“It’s so important, the knowledge she is acquiring,” he said. “As she develops that knowledge, our plans are to develop a primary care oncology fellowship. Primary care physicians need to be educated about the side effects of many of these agents, whether they are receiving targeted therapies, immunotherapy or chemotherapy.”
As she learns through experience, Delaney also attends tumor conferences and visits Graham Cancer Center’s multidisciplinary centers for further education.
Advice for other centers
Petrelli said the program has worked well and he encourages other cancer centers to incorporate primary care practices into their cancer centers. He said he would advise centers that are just starting out to consider hiring advanced practice providers rather than insisting on having a physician in this role.
“From my perspective, getting an advanced practice provider, not necessarily a primary care physician, is key,” he said. “Deb reports to a primary care physician, but advanced practice providers are easier to recruit and she has adapted very well to this.”
He added that being prepared to promote your emerging primary care practice — even within your institution — is essential.
“You have to do a lot of internal marketing to let your three oncology disciplines — medical, surgical and radiation oncology — know that this is available, the hours it’s available and the number to call,” he said. “You have to make it convenient for them to use — easy access. Otherwise, it won’t be successful.”
Delaney said she also considers it valuable for cancer centers to begin where her center did, by investigating how many of their patients lack a primary care provider.
“You can do an evaluation, send out a survey, try to keep track of how many of your patients have a primary care provider,” she said, “Cancer centers may be surprised at how many people out there don’t have primary care and need it.”
Most of all, Delaney said cancer centers should not dismiss or give up on the idea of offering a primary care practice, despite the obstacles they might face.
“Keep evaluating, because our process started as an idea, and it has grown so much,” she said. “It’s just amazing the number of patients who get referred to us.”
- Reference:
- ACCC Innovator Awards / 2022 Winners / Christiana Care. Available at: www.accc-cancer.org/home/about/awards/accc-innovator-awards/2022-winners/christiana-care-health-system. Accessed July 18, 2022.
- For more information:
- Debra Delaney, MSN, RN, ACNS-BC, FNP-BC, can be reached at ChristianaCare, 4512 Kirkwood Highway, Suite 300, Wilmington, DE 19808; email: ddelaney@christianacare.org.
- Nicholas J. Petrelli, MD, FACS, can be reached at ChristianaCare, 4701 Ogletown Stanton Road #1213, Newark, DE 19713; email: npetrelli@christianacare.org.
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