A pilot project that provided nursing case management for frail cancer patients was designed to improve their care and outcomes by making it easier for them to navigate the care continuum.

“The patients we saw were frail patients who, under normal circumstances, would be seen by a different discipline on a separate day and different time,” says Dominique S. Jean-Charles, MSN, MPH, RN, CCM, nurse case manager at Memorial Sloan Kettering Cancer Center in New York City. “We brought the disciplines to the patient so they didn’t have to go to other clinic sites or wait for an appointment,” she says.

Case managers collaborate with the patient’s team, discussing the patient’s needs, reviewing their medical records, and verifying their benefits, she explains. “We look at what their insurance will cover and make recommendations, as well as looking at what is appropriate with their goals of care,” Jean-Charles says.

The team formulates a plan and can initiate it on the same day, contributing to a timely care transition. “We can put services in by the next day, including medical equipment for patients who have Medicaid, and we can initiate long-term care,” she says. “Patients see rehab, physicians, physical therapy, nutritionist, chaplain, and a case manager. It’s holistic.”

The goal is to evaluate all the patient’s needs on a clinical, psychosocial, nutritional, rehabilitative, and spiritual basis, she adds.

Here is how the program works:

• Include all patients. “We see every patient in the clinic,” Jean-Charles says. “The reason is that some patients might not need services, but we can educate them on our role, so they can reach out to us and know we’re a resource and their advocate.”

The holistic team educates patients about their insurance coverage, explaining which services are covered in the hospital and in the community. “We make sure they are aware of what the limitations are,” she says. “Everyone receives that much interaction with the case management team.”

For example, if a family has difficulty caring for the patient at home, then the team evaluates what level of services are needed in the home. These could include Medicaid services, such as home healthcare, Jean-Charles says. “The neurologist and rehab physicians now have a better understanding of what’s covered under insurance: homebound skilled nursing that meets criteria.”

In one case, the family of a patient, who was receiving rehabilitation care, wanted to bring the patient home with home care. They thought that home care services could take care of the patient’s medical needs.

“We discussed with them the realities and what services are required, what benefits are covered, and what they should discuss with rehab,” Jean-Charles says. “We were able to re-evaluate whether this person would be safe to go home, and we determined it was not a safe situation.”

• Evaluate patients’ needed services. “First, we do a clinical review of the medical record,” Jean-Charles says. “Secondly, we have patients walk with physical therapists, and we might see a deficit in their mobility.”

If there is a balance disturbance, the team discusses this with the therapist and asks physical therapy to track the patient’s progress. The patient might need to attend outpatient physical therapy.

“We also look at the patient’s means: Do they have family available, and can they safely receive care while staying at home with the family?” she says. “If not, should we start in the home and then progress to outpatient care?”

Each patient might have certain levels of care that are appropriate, but they also might have families that cannot meet those needs because of other obligations, such as work, she notes.

“We have to look at the whole package and involve the family in the process,” Jean-Charles says. “Some patients might not want to leave their home or have anxiety about leaving their home.”

The team engages in a collaborative discussion with the family, hearing each person’s ideas about what the family and patient need, and which disciplines and settings are appropriate.

• Make referrals. “Prior to meeting with patients, we do a financial/insurance evaluation, looking at what plan the patient has and what it will cover,” Jean-Charles says. “Then, we obtain all the orders and clinical documentation, and we give the patient choices of agencies in their area.”

The team might make recommendations based on the patient’s needs, location, and language. “Once they choose, we process all referrals for our patient,” she says. “We make referrals to appropriate vendors to make sure insurance will at least provide initial authorization and secure visits for them.”

Outpatient services usually include physical therapy, occupational therapy, or speech therapy, she adds. “We can set up appointments for them on the same day,” Jean-Charles says.

If the team cannot make the appointments because the patient chooses local rehab facilities, then the team can instruct the patient how to make these appointments and fax orders directly to those facilities, she adds.

• Collaborate. An important part of holistic care is collaboration between disciplines, Jean-Charles says.

“On a regular basis, a patient might be seen and leave a clinic, and providers say they’ll get services for the patient,” Jean-Charles says. “Later, the patient will say that they never received those services or that the vendor was not adequate.”

With the case management team model, patients do not fall through those cracks. “Immediate collaboration is an important piece in a multidisciplinary clinic,” she says. “The implementation of the care plan is done in real time, and we follow through.”

For example, the team ensures these steps occur with each collaboration and referral:

- The new provider receives all necessary documents;

- Providers review documents and verify insurance;

- Providers give a start date for the patient.

“Particularly for hospice patients, we make sure the patient was seen and they’re actually admitted into services,” Jean-Charles says. “If patients say ‘yes’ to services while they’re in the clinic and then, at home, they process the decision and opt not have the services, we make sure we communicate with them to see if there are any alternative plans we can put in place.”

• Update orders. The team remains patients’ point of contact, and can update orders and notify physicians, as needed.

When patients’ conditions change, the physician and nurse communicate continuously. Also, patients and their families know they can contact the case management team whenever they need help.

“Sometimes, we might see a patient who went into home care, and then declines or reaches a level where we’re managing symptoms and it’s end-of-life care that’s needed,” Jean-Charles says. “There could be a telephone consult with case managers, patients, and family members to initiate hospice services.”

The team might not have believed hospice services were needed while the patient still was in the clinic, but at a later date, circumstances had changed, she adds.

“For hospice and end-of-life care, we do make those arrangements for our patients and try to refer them to hospice as early as possible in that end-of-life stage,” Jean-Charles notes. “Palliative care is not readily available in all geographical areas, so it’s hard to set up by itself.”