Developing and Sustaining an Effective and Resilient Oncology Careforce Proceedings of a Workshop (2019) / Chapter Skim
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Proceedings of a Workshop
Proceedings of a Workshop
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population are contributing to increases in the number of patients diagnosed with cancer. Advances in cancer research, screening and diagnostic practices, and cancer treatment have led to improved outcomes for patients with cancer and a growing population of cancer survivors, but those factors have also increased the complexity of cancer care.
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along with family caregivers. To examine opportunities to better support the oncology careforce and improve the delivery of high-quality cancer care, the National Cancer Policy Forum held a workshop on Developing and Sustaining an Effective and Resilient Oncology Careforce on February 11–12, 2019, in Washington, DC.
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(Nemire) • Provide undergraduate, graduate, and continuing education in palliative care for all cancer care professionals as well as patients.
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• Integrate implementation science and collaborate with diverse organizations to enhance adoption of research findings. (Birken, Van Houtven)
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(Nevidjon, Van Houtven) • Provide funding and staff for palliative care services and program certification, and include palliative care parameters in reported quality metrics.
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• Consult with caregivers on patient symptoms and preferences through "virtual huddles." (Van Houtven) • Use digital tools to more effectively involve and integrate caregiv ers on the care team.
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• Screen patients regularly for their palliative care needs. ( ortman, P Scroggins)
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.3 Brawley noted that even though population-wide mortality rates have declined, cancer care disparities remain a persistent problem. For example, Brawley reported that there are significant disparities in breast, prostate, and colorectal cancer mortality between black and white Americans, and these disparities have worsened since the 1970s (Siegel et al., 2018)
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, and (D) colorectal cancer (female)
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Another factor that may be contributing to the shortage of oncologists is that fewer medical residents are selecting oncology as a specialty, said Anthony Back, professor and co-director of the Cambia Palliative Care Center of Excellence at the University of Washington. He cited a study that found residents reported being less likely to pursue a career in oncology after they completed a ematology/oncology rotation (McFarland h et al., 2015)
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. A nationwide ASCO survey of patients with cancer found that rural patients spend 66 percent more time traveling to receive oncology care than patients living in non-rural areas (ASCO, 2018)
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Mark Hyde, director of advanced practice care at the Huntsman Cancer Institute and professor at The University of Utah, referred to data from the American Academy of Physician Assistants indicating that approximately 30 percent of physician assistants (PAs) report feelings of burnout, with the highest prevalence of burnout occurring between the fifth and ninth year of practice (AAPA, 2018)
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. John Cox, medical director of oncology services at Parkland Health System of the University of Texas Southwestern Medical Center, noted that financial considerations often affect patient care because many patients lack sufficient insurance.
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14 FIGURE 3 Documentation volume for outpatient visits in the United States compared with other countries. SOURCES: Sesto presentation, February 12, 2019; reproduced from Downing et al., 2018.
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Caregiving at Home Lisa Kennedy Sheldon, chief clinical officer of ONS, noted that care ivers g who provide support for patients with cancer are essential members of the oncology careforce. Courtney Harold Van Houtven, research scientist at the Durham Veterans Affairs Medical Center and professor at the Duke University School of Medicine, defined cancer caregivers as "family members or friends, typically uncompensated and providing care at home, who devote significant time, energy, and costs to caring for an individual with cancer." A recent survey found that during a 1-year period, there were at least 2.8 million cancer caregivers in the United States.
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Much of this responsibility falls on patients' family caregivers. Van Houtven noted that informal caregivers face a variety of stressors and challenges, including a lack of training, fragmentation of care, not feeling valued and included in the care team, and economic burden (NASEM, 2016; Rosland and Piette, 2010; Silliman et al., 1996; Wolff et al., 2016)
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health care system," Van Houtven explained. OPPORTUNITIES TO ADDRESS ONCOLOGY CAREFORCE CHALLENGES Given the growing number of cancer survivors, ongoing changes to oncology care, and concerns about the well-being of the oncology careforce, a number of workshop participants discussed potential changes to improve cancer care delivery and better support the careforce.
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The more we can do closer to home, the better patient satisfaction will be if that care is done with the quality and speed that is necessary." Presenters described opportunities to better organize oncology care teams, build capacity for oncology care, and improve well-being of the cancer careforce. These included • Fostering high-performing oncology teams; • Including caregivers on the oncology care team; • Expanding patient navigation services; • Expanding care team capacity with advanced practice providers; • Promoting clinician well-being and fostering a supportive work environment; and • Partnering with community resources.
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. Van Houtven noted that with complex and multidisciplinary teams, it is important to delegate tasks, share knowledge, and understand which team members are responsible for particular aspects of patient care.
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She stated, "They don't want to simply be called when it's time for implementation, but to be a part of the treatment planning.… They serve a purpose that nobody else can serve." Van Houtven also emphasized the importance of integrating caregivers in cancer care, and suggested that caregivers' skills should be assessed and r einforced with relevant training: "It is really important to understand the caregiver's capacity to safely provide care, as so much high-skilled care for infusions and oral cancer medicines are going into the home." She added that clinicians should consult with caregivers on an ongoing basis to assess their capacity to meet patients' needs. At their first visit, patients could be asked what role they want their caregivers to take in their cancer care, and the caregivers could be asked how they would like to be involved.
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Burris stated that the nurse navigation program at the Sarah Cannon Research Institute "has yielded great benefits in terms of efficiencies, the patient experience, and the physician experience. It has been a huge key to our success in a number of areas." Cantril noted that she views navigation as the "hub" of the "wheel of c ancer care" (see Figure 4)
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The navigation program became effective only after it was integrated into the care team so "the patient saw the navigator was not just somebody from the hospital helping with parking and directions, but part of their care team," Rosenthal said. Integrating Palliative Care in Oncology Care Many workshop participants described palliative care as an integral component of cancer care.
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She suggested that this support may involve providing program funding and staff expansion for palliative care services, endorsing palliative program certification per national quality standards, and including palliative care parameters in reported quality metrics. Coordination with hospice and other community-based providers is also needed because not all palliative care is provided at cancer centers, she said.
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. Ruth Nemire, associate executive vice president of the American Association of Colleges of Pharmacy, noted that another strategy to extend the capacity of cancer care teams is to support pharmacists to participate more fully in patient navigation, treatment, and palliative care.
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He also emphasized that it is the responsibility of health care organizations to offer opportunities for clinician renewal during the workday. "It is not the responsibility of clinicians to do this on their own, after they have been at work all day and then done their documentation for 2 to 3 hours at night," Back said.
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. "Quality measures are critical to ensuring safe and effective patient care, but in the current system, they cost too much in terms of human and financial capital," Paz stressed.
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Van Houtven suggested that another way to improve practice efficiencies is to discontinue treatments no longer seen to be effective. Oyer agreed that it is "really important to stop doing things that don't matter, or have unproven or minimal benefit." Partnering with Community Resources Several workshop participants identified community resources to support patients' needs.
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She noted that cancer care teams and health care organizations need to use innovative strategies to broaden their community interface. Levy agreed that corporate community partners can play an important role in reducing barriers to patient care.
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An electronic health record alert system prompts clinicians to provide specific specialty level palliative care services in response to patients' health events. Portman noted that embed ding palliative care in the pathways program can reduce institutional costs, decrease unnecessary health care usage, and improve patient care (Portman et al., 2018a)
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Cantril noted that a key element of the navigation program is its attention to the full continuum of cancer care and its ability to identify and address patients' unique needs at every stage. Sarah Cannon Research Institute's Nurse Navigation Program Howard "Skip" Burris, president and chief medical officer of the Sarah Cannon Research Institute, reported on his organization's nurse navigation program.
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The Effect of New Technologies on Cancer Care Workshop participants discussed ways in which new technologies have changed the delivery of cancer care by improving documentation, patient– clinician communication, health care team functioning, and patient navigation. Technologies that allow for remote patient monitoring and the delivery of telemedicine were discussed in depth.
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Use of Penny was also associated with reduced patient call volume. Project ECHO Kathleen Schmeler, associate professor of gynecologic oncology and reproductive medicine at The University of Texas MD Anderson Cancer Center, discussed her institution's telementoring program called "Project ECHO" (Extension for Community Healthcare Outcomes)
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eConsults Scott Shipman, director of clinical innovations and primary care affairs at the Association of American Medical Colleges, reported on a program called eConsults, which has been implemented at 27 academic medical centers in the United States. He noted that an eConsult is an asynchronous exchange between clinicians that enables a requesting clinician to seek recommendations from a specialist.
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To interpret data generated by remote monitoring, health care organi zations may use algorithms to process patient data and trigger clinical intervention at predetermined thresholds. Portman noted that Moffitt collects and processes data on emotional and physical status to identify patients in need of immediate assistance.
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New technologies have also given patients remote access to palliative care and psychosocial support. Portman noted that Moffitt offers remote palliative care conferencing services to patients for whom distance, cost, or functional status present a burden to travel.
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. She added that PCORI is also studying the effectiveness of video visits versus in-person visits with a palliative care provider for advanced lung cancer patients.
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Mooney suggested that some clinicians may see new technologies as a threat to their role in patient care, rather than viewing them as a helpful tool. "We have to involve clinicians very closely [in the development and implementation of a new technology]
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Strategies to Improve EHRs Many participants commented on clinician burden associated with EHR use and proposed strategies to improve EHR design, implementation, and use. Participants frequently commented that EHRs have poor usability, which Sesto defined as "the effectiveness, efficiency, and satisfaction with which specific users can achieve certain tasks in an environment." Sesto added that EHR users are often frustrated by elements of poor design, such as text boxes that are too small to fully display text and requirements for redundant documentation.
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Noting that many new technologies discussed during the workshop require access to broadband Internet, Dentzer suggested developing a national plan for universal broadband and universal 5G technology. Robert Winn, director of the University of Illinois Cancer Center, agreed, noting that inequalities in access to Internet services have the potential to widen geographic health disparities as Internet services become critical for health care access.
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Advanced practice registered nurses, by contrast, have created a compact that allows them to have one multistate license that enables practice in all states that have joined the compact. Dentzer suggested that laws and regulations should be modified in every state to enable clinicians to deliver telemedicine consultations across state lines.
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Within a fee-for-service reimbursement model, health care providers are reimbursed for care based on a medical code associated with each service they provide. Kline, Lichtenfeld, Shulman, and Van Houtven noted that tying payments to the medical coding system limits health care innovation, and often fails to account for or compensate clinicians for important aspects of cancer care, such as the provision of palliative care, clinical encounters with the patient's family, and consultations with other clinicians about a patient's care.
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, a value-based care delivery model designed to improve quality and value in oncology care. He noted that OMH focuses on patient experience and encourages health care organizations to inno vate to improve patient care.
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Support for Caregivers Van Houtven suggested that one strategy to develop and sustain an effective and resilient oncology careforce is to create policies that provide support for patients' caregivers (NASEM, 2016)
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Van Houtven proposed that oncology organizations and professional societies, such as ASCO and ONS, could serve as partners in developing new clinical curricula. Hyde suggested that an important strategy for increasing oncology care capacity is training APPs to allow them to practice more autonomously.
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The training program for nurses, social workers, psychologists, and chaplains is customized to their scope of practice, and consists of three modules. One module in this program helps teams develop systematic approaches to proactively identify high-risk patients, prepare patients and their families for these conversations, and ensure accurate and comprehensive documentation.
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Patients and the public also need to be more educated about palliative care, Scroggins noted. She said many patients have the misconception that palliative care is only appropriate at the end of life.
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WRAP-UP Shulman provided the workshop wrap-up, in which he summarized the discussion and suggested next steps for developing and sustaining the oncology careforce. He noted that delivering high-quality patient care is the goal for all oncology clinicians, but oncology is challenged by the growing number
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Shulman stressed that technology needs to be designed and implemented in partnership with the oncology careforce. Shulman ended his remarks by quoting Winston Churchill, who said, "Difficulties mastered are opportunities won." He suggested that participants should work to turn the difficulties discussed at the workshop into opportunities to support the oncology careforce and optimize the delivery of highquality oncology care.
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2016. Building resilience for palliative care clinicians: An approach to burnout prevention based on individual skills and workplace factors.
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2018. National consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition.
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2018. Pharmacists providing palliative care services: Demonstrating a positive return on investment.
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2018a. Standardizing palliative care and oncology integration using assessments and care pathways: Moffitt Cancer Center's approach.
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Kahn, C van Houtven, J
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2017. Telemedicine and palliative care: An increasing role in supportive oncology.
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