Oncology CMs guide patients through treatment

Program helps with symptom management

Capital BlueCross members who have been diagnosed with cancer are getting support during all phases of treatment through a new oncology case management program launched in the spring of 2010 by the Harrisburg, PA-based health plan.

The health plan added oncology case management to its specialty case management program after determining that 20% of the patients receiving case management services have a diagnosis of cancer, says Jennifer Chambers, MD, MBA, FACP, medical director at Capital BlueCross.

"Patients with a diagnosis of cancer have a unique set of issues. When they hear the word 'cancer,' they tend to shut down, and when they come out of the doctor's office, all they remember is that they have cancer. We created this program to support them during this challenging time," she adds.

The case managers who work with cancer patients are nurses with extensive case management, home care, and/or oncology experience. They work with Chambers, who is board-certified in internal medicine and palliative medicine, to coordinate care for patients who have been identified through hospital admissions, referrals from physicians, and self-referrals.

The purpose of the program is to help members and families work through difficult issues such as treatment options, symptom management, and life-care planning, Chambers says. Case managers are trained to help patients understand their disease and their treatment options. They help them access educational resources such as the American Cancer Society and the National Cancer Institute and assist them in compiling a list of questions they should ask their doctor at their next appointment.

"We know from evidence-based data that there are five domains where case managers can make a difference: empowerment, adherence and compliance, coordination of care, knowledge, and safety," Chambers says.

Empowerment is the portal to all the other domains, Chambers says.

"When members are educated and understand their treatment plan, they start to feel a sense of control. They may not be able to control the cancer, but they can control when and where they receive treatment, when to make the decision about palliative care, and who to see for a second opinion. We want members to feel educated and informed," she adds.

Patients undergoing cancer treatment often are treated by multiple physicians, including a surgical oncologist, a medical oncologist, and a radiation oncologist, as well as their primary care physician, Chambers says.

Case managers often coordinate with the various treating physicians to make sure they are fully informed about other treatments the patient is receiving, and attempt to coordinate times and arrangements for numerous medical appointments.

They also may consult with treating physicians to advise them of concerns or challenges voiced by patients.

"A primary goal for case managers is to help patients navigate through the health care system and feel more comfortable in making decisions with their doctors. We don't make treatment decisions for the members; we help the members with questions they need to ask to make the best decision for them," Chambers says.

They address safety issues with patients, such as whether they have someone to provide transportation or assist with care at home. They advise them on how to prevent infection and suggest overall ways they can improve safety in the home.

Once patients say they are interested in participating in the program, the nurse case manager completes an assessment to identify the patient's needs and helps him or her develop individual goals and plans.

The case managers base their interventions and frequency of follow-up on the needs each member identifies.

They make periodic calls to check on the patients' progress and work closely with the patient and the treatment team to address any concerns or questions.

"We find these phone calls are very helpful because they provide a sense of confidence and empowerment for the member. They ask the patients about their goals and what they need to accomplish them. The case managers listen to the patients and offer their support and encouragement," she says.

The case manager closes the case when the plan of care developed by the member and case manager is completed and no further needs are identified. If patients need further treatment or support, they may become actively involved in case management again.

During their interventions with the patients, the case managers encourage them to have advance directives in place.

When a patient's cancer progresses to the point that he or she needs palliative and/or hospice care, the case manager helps facilitate a discussion with the physician and gives the patient information about palliative care and hospice options and providers.

"Some patients never want hospice care. They want to continue treatment even if the cancer can't be cured. But they do want help with pain and nausea. What happens is always the choice of the member. If people are making a conscious decision not to have hospice care, the case managers help facilitate management of symptoms," Chambers adds.

The oncology nurses meet with their supervisor on a routine basis to discuss their feelings and experiences in dealing with patients with a life-threatening disease.

"The case managers are either experienced hospice nurses or oncology nurses, but they often need support in coping with caring for terminally ill patients. They talk about when they are feeling sad and when they need to take a break and do self-care," she says.

The health plan team spent about nine months developing the program and ensuring that everything the participants will need was in place.

"We like to start working with these patients as early as possible or as soon as they're ready to participate," she says.

The health plan mines its claims data to identify patients who have been hospitalized with a primary or secondary diagnosis of cancer and makes an outreach call after the patients are discharged, following up with a letter asking if the patient would like to participate in the program.

"Some patients aren't ready to participate just after diagnosis. It's an individual decision. Our case managers are there to help them whenever they are ready for assistance," Chambers says.

Initial participants in the program range from patients who have just had surgery for cancer to those who are entering hospice, Chamber says.

"As the program progresses, we anticipate that we will be enrolling the majority of patients in the program much sooner in their cancer treatment regimen," she says.