How to Close Care Gaps in Vulnerable Populations

In a multi-presenter session during the 43rd Oncology Nursing Society Congress, four oncology nurse leaders shared their perspectives on a range of ways to improve daily practice in the care of vulnerable oncology populations-from triage in the emergency department to tailored telehealth sessions. The presentation, “Closing the Gap Between Quality Health Care and Vulnerable Populations,” highlighted strategies for providing high-quality healthcare to special populations, including patients with lung cancer; homeless populations; patients presenting with medical emergencies; and the older adult.

TIP 1: Approaches to Improving the Management of Patients With High-Risk Lung Nodules

In her presentation, “Creation of a Multidisciplinary Lung Nodule Center: An Innovative Care Model for High-Risk Lung Nodules,” Michele Gaguski, MSN, RN, AOCN, CHPN, NE-BC, APN-C, from the Sidney Kimmel Cancer Center, Jefferson Health in Sewell, New Jersey, explained that patients found to have incidental lung nodules on diagnostic CT are especially vulnerable given the sometimes-extensive failure of oncology staff to follow up with patients or follow through on recommendations.

Gaguski explained, “About 14% of all new cancers are lung cancers. Each year, more people die of lung cancer than from colon, breast, and prostate cancers combined. Lung cancer is often diagnosed at a later stage, contributing to a higher mortality rate. The earlier you can diagnose people at risk for developing lung cancer (such as current or former smokers) there is opportunity for an improved clinical outcome and enhanced quality of life.”

Recognizing the need for comprehensive management of this population, Gaguski’s institution developed a dedicated Lung Nodule Center (LNC), with the goal of offering a multidisciplinary approach to managing patients’ lung nodules with teams of nurses, nurse navigators, certified tobacco treatment specialists, pulmonologists, thoracic surgeons, interventional radiologists, medical and radiation oncologists, and other appropriate healthcare providers.

“The patient is at the center of our Lung Nodule Center’s (LNC) model of care,” Gaguski told Cancer Network. “Our multidisciplinary team receives referrals from various sources, such as primary care providers and eligible patients who have had low-dose CT lung screening. Our approach consists of expediting the patient’s appointment in the LNC via our dedicated nurse navigator, who speaks with the patient and provides an initial overview explaining what to expect during the LNC visit. The nurse navigator works in concert with our pulmonologists and thoracic surgeons to help patients with high-risk nodules navigate next steps in their plan of care; this may include EBUS [endobronchial ultrascound] or stereotactic radiation therapy or surgery.”

“A novel [aspect] of our program,” Gaguski explained, “is that the patient is seen and evaluated by both the thoracic surgeon and the pulmonologist on the same day in the clinic-so there is just one initial office visit for the patient. Patients will be scheduled for a follow-up visit based upon the results of their initial evaluation. During clinic hours, the patient can also have PFTs [pulmonary function tests] performed and follow-up tests scheduled, and can engage with the nurse navigator-a certified tobacco treatment specialist (CTTS)-for smoking cessation counseling. Our patient satisfaction scores for overall satisfaction are consistently above 95%.”

Through the cooperative efforts of the LNC, Gaguski said, at-risk patients are afforded a same-day discussion in their multidisciplinary pulmonary care conference, along with a same-day physician evaluation. Through this program, she added, the team has also been able to fast-track cardiac clearances, and time to procedure and surgical interventions, as clinically indicated.  

Most of the patients referred to the LNC are physician referrals, followed by patients referred following lung screening, and then self-referrals, Gaguski said. On average, the team at the LNC evaluates approximately 9 patients at each session, and the turnaround time is approximately 10 working days from referral to LNC visit.

“Since the inception of the program,” Gaguski told Cancer Network, “our referral and procedural volumes have grown, and we have been able to identify early-stage lung cancers and decrease turnaround times for treatments such as surgery, certain procedures (such as navigational bronchoscopy), and cardiac clearance. We have elevated awareness surrounding the LNC through digital [marketing], social media [promotion], and in-person marketing of our program; we are now well known within our physician network and the community for providing this unique service to patients identified with high-risk lung nodules.”

“From the initial referral to treatment and follow-up care, this evidence-based model of care provides a seamless patient experience which is the result of a high level of engagement; clinical expertise; and support by our physicians, nurses, clinical team, and administrative staff,” she said.

TIP 2: Use Telehealth to Address Health Vulnerability in Homeless Populations

Patient vulnerability extends to the homeless, who often lack access to healthcare, struggle with health literacy, and are at risk for the development of several cancers. Loril Garrett, MS, BSN, RN, OCN, CBCN, CMOM, clinical nurse manager at Spectrum Health in Grand Rapids, Mich., discussed how to use telehealth to address this issue, in her presentation, “Telehealth Technology Reaches Homeless With Cancer Risk Reduction Education.”

Spectrum Health is responsible for diagnosing more than 3,500 cancers annually, and has put telehealth technology programs in place to aid with cancer screening and patient care. Spectrum Health and Mel Trotter Ministries (a local homeless shelter) partnered to provide telehealth cancer screening education and risk-reduction education to the homeless population residing at Mel Trotter. During the telehealth visits, the participants, from 18 to 77 years of age, were interviewed by oncology nurses who followed a script asking about age and family cancer history, and provided relevant cancer risk–reduction strategies to the guests based on guidelines from the American Cancer Society, in an intake-and-recommendation format. As Garrett explained, the goal of this project was “to reach the homeless in our community with cancer screening education and cancer risk–reduction education, through a collaboration with Mel Trotter Ministries (an already well-established homeless shelter) and the Spectrum Health Cancer Program.”  

During telehealth sessions, patients were counseled on topics including:

•Exercise/physical activity
•Diet and nutrition
•Family cancer history
•Smoking cessation
•Cancer screening recommendations
•Knowing what is normal for them
•Limiting alcohol
•Weight maintenance/BMI
•Other cancer-related education (answering questions from the guests)

Garrett and her team found that the telehealth sessions with Mel Trotter residents had a powerful and significant impact, with more than 50% of the guests reporting the intent to make health changes. “The homeless are identified as a vulnerable population, at risk for many cancers, and are underserved in the area of health education,” she said. “Having an oncology nurse explain the basic concepts of cancer screening and cancer risk–reduction strategies proved effective in inspiring homeless guests to take on more ownership of their health. Many had misconceptions about cancer and their ability to reduce their risks. Interestingly, if guests were to follow the American Cancer Society’s cancer risk–reduction strategies, they would also reduce their risk of heart disease in the process, because many of the recommendations overlap.”

The Spectrum Health team also learned that:

•It is possible to use current infrastructure in new and innovative ways to optimize investments and the health of the communities served.
•Partnering with already-successful community-based organizations is an effective strategy to reach more people with cancer-prevention education.
•Utilizing telehealth technology is an effective way to reach the homeless with cancer-prevention education, and it may be feasible to use in other underserved populations.

When asked about the future of this program, Garrett commented that “it is our hope that the program will continue once space to house the equipment is reallocated at Mel Trotter Ministries.”

TIP 3: Manage Oncology Patient Emergencies While Minimizing ED Visits

Patients with cancer often present to the hospital emergency department (ED) with conditions that are not actual emergencies or with symptoms that can be managed in an outpatient setting; however, many are left with no other choice but to present to an ED during off-clinic hours. Elizabeth Malosh, MSN, RN, NE-BC, Nursing Manager of Ambulatory Cancer at Froedtert & the Medical College of Wisconsin (MCW), discussed her presentation, “24-Hour Oncology Clinic: From Concept to Reality,” highlighting the implementation of a 24-hour oncology clinic at Froedtert & MCW.

The need for a 24-hour oncology clinic arose from an increase in oncology volume and activity, coupled with a lack of after-hour plans for after-hours emergency situations, which do not always require a visit to the ED or use of ED services. Malosh explained that the use of ED services at her center often resulted in unnecessary tests and hospital admissions in the oncology population; these included ED visits for lab rechecks, de-accessing of a mediport, arm pain and swelling, and non-neutropenic fevers. In her presentation, Malosh highlighted the problem by noting that, during the ED chart review process, of the 55% of patients admitted to the hospital and 5% admitted to the ICU, 22 had received care in the cancer clinic earlier the same day.

Malosh emphasized that, “Due to the rigors of cancer treatment, patients often require additional supportive care at all hours of the day or night.  Most often, these complications do not require the level of care provided by the ED, but rather a more tailored approach by an oncology provider who understands the nuances of cancer care and symptom management. This has led to a decrease in repeat testing and cost to the patient, as well as high patient satisfaction, given that patients do not need to ‘explain’ their cancer to the providers caring for them.”

These findings prompted the development of a dedicated 24-hour oncology clinic where patients could be evaluated by their oncology providers and treated for urgent symptoms, in order to reduce ED service utilization. Within the 24-hour clinic, patients are evaluated by oncology nurses and physicians for symptoms of fever, dehydration, nausea, vomiting, rashes, urinary problems, and other treatment- or disease-related symptoms. Management services offered are billed at the clinic rate vs the ED fee schedule, and include services such as supportive care, administration of fluids, blood draws and testing, medications, obtaining urine and other samples for laboratory testing, urgent issues with CVL/IV line access, radiology services, and other non-emergent services that would otherwise require a visit to the ED-or hospital admission-to achieve.

In addition to noting high patient satisfaction rates, Malosh reported a 10.7% reduction in ED utilization following implementation of the dedicated 24-hour oncology clinic, with lower hospital admission rates compared with rates charged through the ED (18% vs 45%). In addition, use of the oncology clinic resulted in lower emergency-service costs to patients.

“This program has been successful because it was the right thing to do for patients, Malosh said. “Since this type of offering is not commonly found in cancer centers currently, it did take time and attention to build trust with the providers, and to establish a foundation for how this service can best be integrated into the patient’s treatment plan. Overall, our patients and their satisfaction with the program have truly driven our success.”

TIP 4: Build Nursing Skills to Improve the Care of Older Patients With Cancer

Older individuals are widely known to be a particularly vulnerable group within the cancer patient population, and account for many of the patient visits seen in inpatient, outpatient, and long-term-care settings. In her presentation, “Oncology Nurses’ Self-Rating of Skill, Preparation, and Comfort Level in Caring for Older Adults,” geriatric oncology Clinical Nurse Specialist Peggy Burhenn, MS, RN-BC, AOCNS, from City of Hope, Duarte, Calif., discussed the need to develop a national curriculum to adequately prepare and evaluate nurses caring for older patients with cancer.

Burhenn explained that the lack of gerontology training among cancer professionals is a problem nationwide, with only 34% of BSN programs offering dedicated gerontology training courses. In addition, currently in the United States, fewer than 3% of registered nurses are certified in gerontology, and NPs and CNS professionals specializing in gerontology account for fewer than 1% of practicing providers. Recognition of this need led Burhenn and the team at City of Hope to apply for and receive an R25 grant to develop a program that would educate nurses about strategies to improve the quality of cancer care in the geriatric population.

Burhenn pointed out that “Very few healthcare professionals have expertise in gerontology, yet the majority of our patients are older adults. The IOM [Institute of Medicine] has called for enhancing the geriatric competence of all healthcare professionals. We surveyed oncology nurses and oncology nurse executives and identified a need and an interest in learning to care for older adults with cancer.”

In a survey that Burhenn and coinvestigators administered, nurses caring for geriatric patients reported on a scale of 1 to 5 (with 5 ranked highest), an average of 3 in their self-assessed skill level to care for older oncology patients. Nearly all, 94%, expressed willingness to travel to be educated further in the care of geriatric oncology patients.

“Nurses who completed the course felt more skilled and more comfortable in caring for this population, and they said that their organizations were more prepared to care for older adults,” Burhenn told Cancer Network. “This course asks a team of nurses from each institution to attend together and develop a plan to integrate the new knowledge into their organization when they return from the conference. This action plan may help to reinforce the knowledge and hard-wire gerontology practices into their organizations.”

Most nurses attending the program were Bachelor’s or Master’s degree–prepared nurses, with each team comprising a direct care nurse, a nurse educator, and a nurse manager. Pre- and post-course testing showed that the course improved nurses’ knowledge with respect to geriatric care. “We hope this program will send a ripple effect through organizations to improve care for older adults with cancer, Burhenn said.”