Disclosures: Mooney reports no relevant financial disclosures.
April 23, 2021
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APPs should take proactive role in advancing new models of oncology care delivery

Disclosures: Mooney reports no relevant financial disclosures.
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APPs are integral to cancer care delivery, working across the cancer continuum from prevention, risk reduction, screening and diagnosis to all modes of treatment, post-treatment survivorship and surveillance, and end-of-life care.

Kathi Mooney, PhD, RN, FAAN
Kathi Mooney

APPs provide care in both academic and community cancer programs and for all types of cancer diagnoses and clinical specialties. As a result, they have a major impact on the quality of cancer care.

In addition to traditional practice roles, APPs have branched out to develop and lead innovative services, such as those in survivorship or urgent care. Identifying and capitalizing on an area for improvement in their cancer program, APPs can bring their skills and talent to redesign care and provide new oncology services.

Beyond fulfilling a current job description, APPs can identify their next steps in professional advancement by taking a proactive role to advance APP models of care that add value in oncology.

Finding, advancing new opportunities

As I discussed during an education breakout session at Oncology Nursing Society Congress, there are a variety of approaches to proactively identify areas that could benefit from APP leadership.

If you have an active quality improvement committee, consider joining it. This may advance ideas where APPs could help to formulate quality improvement studies and initiate practice change and new roles.

Group support and joint projects are excellent ways for APPs to increase their clout across clinics and services.

Begin with a problem focused on something that is important to your organization or practice group, as this will increase the likelihood of generating broader interest and support. What are the pain points in your organization? Is there a problem with high rates of 30-day hospital readmissions, adherence to oral therapies, complaints about wait times, or low accrual to clinical trials? What might APPs propose to address these common problems in oncology?

Often it is important to begin by gathering data about the problem within your organization or practice group, so people realize that your organization or practice is not immune from these problems.

Analyze how best to advance your idea. Is there a physician or administrative champion you can enlist who can help advocate and support the project? Is there a particular pathway — at specific meetings or committees — that would be most effective to present the idea?

Do your homework. Who are the key stakeholders and what will be the barriers? A common roadblock usually relates to funding. How will you overcome this as you present your ideas?

Think about other pushback you may get — for instance, from those who likely will say, “it will disrupt workflow,” or, “I like it the way it is.”

You need to employ a little psychology to move new ideas forward. For example, can you pilot the idea first to show effectiveness and high patient satisfaction?

Also, delineate your benchmarks for success. How will this benefit the cancer program or clinical practice, and what are your deliverables? Consider using a model of a successful prior initiative in your organization and follow how it was proposed and implemented. Be sure to add an evaluation component so you can show the impact and added value.

Disseminate your success widely within your organization, so everyone knows the contribution you are making as APPs, and also outside your organization, so other APPs and cancer care organizations see the APPs’ role and contributions to advancing quality cancer care. Don’t be shy — be sure to say that it is an APP-led model of care.

The hospital-at-home example

For several years, there has been a growing national discussion about expanding sites for cancer care. This discussion has been prompted by hospitals and EDs operating at capacity and a need to utilize these sites for care that cannot be performed in other locations.

In oncology, these discussions recognize the burden on hospitals and EDs to accommodate unplanned acute episodes of care due to adverse effects of treatment and symptoms of disease progression.

One untapped point for cancer care is the home. How might this address some of these pain points for oncology? There is mounting research demonstrating that symptoms can be monitored and treated successfully in patients’ homes, aided by remote patient-reported outcomes technology, resulting in fewer ED visits and improved symptom outcomes.

In addition, international models of care, such as the hospital-at-home concept, have demonstrated that acute-level services can be safely provided at home, avoiding a lengthy hospitalization.

These discussions about home as a site of care have rapidly accelerated since the COVID-19 pandemic, during which ED use, clinic visits and unplanned hospitalization add risk to patients and bed capacity is stretched. These promising models of care in the home also better address the needs and preferences of patients, allowing more time at home and the comfort of being with family.

The Huntsman Cancer Institute at University of Utah has long employed APPs, both physician assistants and nurse practitioners (NPs), in all aspects of cancer care delivery. Years prior to the pandemic, our studies of remote, automated home symptom monitoring of patients receiving chemotherapy demonstrated dramatic reduction of symptoms when the remote monitoring alerted a NP team about poorly controlled symptoms and the NPs responded to intensify the symptom care.

This proactive approach to symptom monitoring and management resulted in a 67% decrease in symptoms reported at severe levels (score of 8-10 on a 10-point scale) and a 40% decrease in symptoms reported at moderate levels (score of 4-7) compared with usual approaches to symptom care.

Based on this positive experience, we examined how APPs could further extend care to the home utilizing a hospital-at-home model and admitting patients to home, still requiring acute hospital-level care. We established “Huntsman at Home,” led by a team of NPs, in August of 2018 after partnering with a home health organization for registered nurse and other multidisciplinary services.

A challenge to this model of care in the U.S. is that home reimbursement of acute care is not adequately covered in the current fee-for-service world. Thus, Huntsman at Home began as a demonstration project with philanthropic and foundation support. A key objective was to gather evaluation data so we could determine the value added, including the avoidance of unplanned hospitalizations and subsequent 30-day readmissions, decreased ED visits and lower costs to discuss new reimbursement models with our payers.

Our evaluation of the first 15 months of patients admitted to Huntsman at Home found a significant reduction in unplanned hospitalizations and ED use, as well as lower cost, compared with the usual-care group. We also found increased patient and family satisfaction and enthusiastic support from our oncology teams.

These new models of cancer care delivery for patients at home have shown significant benefits in addressing health care utilization bottlenecks, decreasing costs, protecting patients against nosocomial infections and increasing time at home with family.

Importantly, these models of multidisciplinary clinical care are developed and led by APPs. Your talent, skill and innovative ideas can bring fresh solutions to improve cancer care and drive new services. Now well-integrated into cancer care, APPs have the opportunity to imagine and lead these advances.

References:

Basch E, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2015.63.0830.

Corcoran S, et al. Semin Oncol Nurs. 2015;doi:10.1016/j.soncn.2015.08.009.

Mooney K, et al. Cancer Med. 2017;doi:10.1002/cam4.1002.

Mooney K, et al. Abstract 7000. Presented at: ASCO20 Virtual Scientific Program; May 29-31, 2020.

Wilson CM and Mooney K. Semin Oncol Nurs. 2020;doi:10.1016/j.soncn.2020.151087.