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Symptom Management Drives Value in Oncology

TOP - February 2015, Vol 8, No 1

San Diego, CA—The development of standardized methods of patient assessment through a symptom management clinic (SMC) leads to better quality care, improved patient satisfaction, and a significant reduction in costs, according to a study presented at the 2014 Association of Community Cancer Centers’ National Oncology Conference.

For Lynn Graze, RN, MSN, OCN, Nursing Director at the DeCesaris Cancer Institute of the Anne Arundel Medical Center in Annapolis, MD, the idea for the symptom management clinic emerged from a drive to achieve higher-quality care at lower cost.

Establishing the Symptom Management Clinic
In 2011 “we started to see that systematic nursing assessments with interventions lead to better quality of life for patients. We also saw that unrelieved symptoms lead to a decline in physical state, performance status, and increased suffering. So we knew we had to treat these symptoms early,” Ms Graze said.

Untreated symptoms cost payers too. “We knew that if a patient has to go to the ED [emergency department] for oncology symptom management, they have a better than 50% chance of being admitted,” said Ms Graze. “So we really wanted to alleviate these [symptoms] with earlier care for our patients.”

Despite this incentive, establishing the symptom management clinic was not easy. Lack of standardized assessment tools, equipment, digital support, and staffing issues all posed barriers. Perhaps the biggest obstacle, Ms Graze said, was psychological.

“Patients do not like to bother their physicians….The communication of symptoms during office visits is flawed compared with concurrent diaries of symptoms; what patients document as their symptoms is not what they’re telling their physicians.”

Accurate patient assessment is critical to cost-savings by providing the right care at the right time and place, with fewer dose modifications. The symptom management model was developed with the patient perspective in mind. “We needed to find a way to make care easier for the patients,” said Ms Graze. “We wanted to get to symptoms early, treat them, and keep patients out of the ED….Patient education was critical.”

Run by nurse practitioners (NPs) and triage nurses, the clinic provides rapid access and coordination of care with the oncologists and infusion team. If 1 of 19 criteria is met, a patient can automatically be put on the NP’s schedule. Triage phone lines are answered by infusion nurses and average between 70 and 100 calls daily.

“We didn’t extend the clinic hours,” said Barry R. Meisenberg, MD, Chair for Quality Improvement and Healthcare Systems Research, Anne Arundel Medical Center. “We just made it easier to reach us during clinic hours.”

Significant Results
A study conducted by the hospital showed good results for the symptom management clinic in the first 8 months. Overall, 41 patients were seen monthly in the clinic for pain, anorexia, nausea, vomiting, diarrhea, swelling, and fever. Of these, 65% of patients were seen the same day and 25% were seen the following day.

Emergency department visits went from 26 to 17 monthly, a 35% reduction.

“We didn’t invent symptom management. There’s probably a description of this in Homer with the Greek army and the gates of Troy….What we were able to do was embed the SMC within the larger oncology clinic, and we achieved a 35% reduction in ED visits,” said Dr Meisenberg.

He said the study proved that a significant percentage of non–chemotherapy-related admissions could be prevented with little effort, without overhauling the oncology care model.

“We have to expand the concepts so we’re taking care of not only the patients on our clinic schedules, but the patients who are not on our clinic schedule. We basically need an alternative roster of patients that we’re managing via the phone and the triage,” Dr Meisenberg emphasized.

“The financial incentive is there, and we can make the case to our payers that this is important for us to do for more than one reason. It’s also good patient care,” he concluded.

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