Oncology CM helps clients with treatment, survivorship

Practitioner contracts with patients, families

Working from her Chicago home, Susan Moore, RN, NP, uses her expertise gained from years as an oncology nurse practitioner to help cancer patients and their family members explore treatment options, advocate for them through the continuum of cancer care, and support them whenever they have a question or a concern.

"Today's cancer treatments are very complex, with multiple options and choices and new treatment regimens coming on the market almost every day. As a case manager, I help patients with whatever needs they have, whether it's choosing the right treatment option, helping ensure their medical needs are met, or just being there when they need someone to talk to," Moore says.

Moore was a nurse practitioner in the ambulatory clinic of the department of hematology and oncology at Rush University Medical Center in Chicago before she started her independent practice. Most of her patients are referred by an oncologist or an oncology nurse and about 60% of them live outside of Chicago.

Patients or their family members pay for Moore's services, usually on an hourly basis.

Insurance does not pay for Moore's services, although she has been hired by insurance companies to provide case management for difficult cases.

"Some insurance companies don't have a nurse case manager or anyone on staff who is experienced in oncology. They use me as a consultant," she says.

Patients on the lookout for independent CM

Many of her patients are newly diagnosed with cancer and want someone to guide them through the treatment maze or those who need support during active treatment.

Some clients want a second opinion and don't know where to go or are having problems getting an appointment. In some cases, the physician who referred them doesn't have the support staff to do the legwork or doesn't know who to call for a particular diagnosis, Moore says.

"I have been in oncology for a long time and know people all over the country. I know who to call for particular cancers. For instance, breast cancer is a more aggressive disease in young women and I can recommend doctors who specialize in treating younger patients," she says.

Other clients have received a second opinion that is in conflict with the first opinion and want help sorting them out and choosing the best options, and others have cancer that has spread and want to explore clinical trials.

"There are numerous clinical trials being conducted in a variety of settings but community physicians don't always know about all of them nor have the time to research them on the Internet. A case manager can advocate for patients whose disease has spread and who need access to these kinds of trials. I can recommend a place for a second opinion and will go with the patient if they feel they need a medical professional to help them through the appointment," she says.

Some of her clients are women with strong family histories of breast or ovarian cancer who want advice on where to go to be monitored. These typically involve one or two consultations, Moore says.

When Moore gets a referral, she talks to the potential client on the telephone and explains her services. There's no charge for the initial call but if the patients do decide to contract for Moore's services, she starts charging fees after the initial call and when a contract is signed by the client.

If patients are within 100 miles of her home, Moore sets up a face-to-face meeting at their home or another convenient location. Subsequent contacts may be by telephone, e-mail, or in person, depending on the situation.

Not every referral ends up in a face-to-face relationship, Moore says. Some consultations are conducted strictly by telephone or e-mail, if the patient isn't in the Chicago area.

"When I have the opportunity to meet the patient and family members, it's helpful when other issues come up because I know what I'm dealing with in terms of family, friends, and other support," she says.

With patient consent, Moore arranges to have copies of the patient's records sent to her, reviews them, and talks with the physician to find out more information.

All in a day of a consulting CM

Moore follows her patients through their treatment regimen, supporting them in person or by phone or e-mail at regular intervals and advocating for the patients when they need them.

For instance, she makes sure that the patients are receiving appropriate medication to help manage the side effects of chemotherapy. She negotiates with the insurance companies if they won't cover the patients' recommended treatments or supportive care.

If a patient who is undergoing treatment has health-related or treatment-related problems at work, she mediates with their employer to make sure that job accommodations that qualify under the Americans with Disabilities Act are met.

For instance, one client was advised by his doctor to take a leave of absence from his job as a special needs teacher because his compromised immune system would make him vulnerable to infections he might be exposed to when he worked directly with the children.

The client told Moore he had to keep working because he was the primary breadwinner in the family and the limited disability income would be insufficient to meet his family's financial needs.

She was able to intervene with the employer and have the client transferred to a counseling position for the duration of this therapy.

"My job is to oversee treatment and make sure the patients are referred for clinical trials, ensuring that they get the correct sequencing of care and that their supportive care needs are being met. I work with them on disability issues and make sure the insurance companies are reimbursing for the kind of care the patients need," she says.

Often, she's asked to accompany patients when they go to the doctor for a second opinion and to explain the options in a language that laypeople can understand.

If the patients live out of town, Moore is willing to travel to meet them as long as the patient pays for travel expenses and time involved for the visit.

In one instance, she made bi-weekly trips to Jacksonville, FL, to oversee an elderly woman's chemotherapy treatments for metastatic colon cancer. She sat with the woman during the treatments and stayed overnight in a nearby hotel until she was sure the woman wasn't having side effects from the treatment. She was hired by the patient's children, professionals in the Chicago area who couldn't go to Jacksonville every other week.

With years of experience in working with oncology patients, Moore can sometimes see issues that the nurse or doctor who is caring for the patient might not see because they don't have the time to spend with the patient.

"If I see a situation where symptom management could be better, I make a phone call to the nurse, tell her what I observed and make suggestions. Having a case manager on the job adds another person who is watching over the patient and looking out for them," she says.

The same is true with physicians and office staff, she adds.

Often, oncologists are too busy and concerned with clinical issues to give patients the emotional support they need, Moore points out.

"The nurses in the infusion center do listen and provide support to the patients but they're overwhelmed by a high patient volume as well and they may not be able to take a telephone call at 9 p.m. from a patient who primarily needs reassurance," she adds.

(For more information, contact Susan Moore, e-mail: susan.moore@cancerexpertise.com.)