Discharge Planning Advisor

How to define risk factors among cancer patients

"How do you identify patients who are most at risk when all of your patients have cancer?" That’s the question posed by Mary Gilbert, BSN, CCM, oncology care coordinator at the Regional Cancer Center in Waukesha, WI. "There must be one or two triggers that will identify someone as being at more risk," Gilbert says. "Many of the traditional identification systems we’re struggling with because everyone we see has cancer."

Another part of the challenge, she adds, is to better define the facility’s more global care management. The Regional Cancer Center serves two hospital campuses, one of which — a 275-bed facility — has a dedicated oncology unit of 15 beds, four of which are designated for stem-cell transplants. The other hospital, which has 130 beds, cares for oncology inpatients on a medical-surgical unit. Both hospitals have outpatient medical and radiation clinics for cancer patients. "We have about 900 to 1,000 new cancer cases per year," Gilbert notes.

The Regional Cancer Center currently has no formal case management program, but it does take a care management approach in selected areas, Gilbert explains. For instance, a nurse practitioner is dedicated to coordinating the care of patients undergoing peripheral stem cell transplant, leukemic/hematological patients, and other clinically complex patients.

A coordinator at the Center for Breast Care navigates women through the system from suspicious mammogram through biopsy, initial treatment, and supportive follow-up, she notes. Another professional supports men through the diagnosis and treatment options for prostate cancer. Most recently, Gilbert says, a palliative care coordinator has been added. That coordinator identifies, assesses, and supports patients for whom treatment is not expected to result in a cure, she adds. "We are still deciding how long and to what degree [the palliative care coordinator] will follow those patients."

The nurse practitioner who works with the stem cell transplant patients stays with them throughout their care, Gilbert notes. The coordinators who work with the patients who have breast and prostate cancer, however, are involved primarily in the diagnostic and early treatment phase of care. After that, she adds, those patients’ care is overseen by Gilbert and the other oncology care coordinator. "The biggest question revolves around the majority of other patients — how to identify who is at risk and/or who needs case management, and to help patient and family through different referral systems," Gilbert says.

A few years ago, Gilbert began screening for certain risk factors. Those included: an elderly person with cancer who’s the caregiver for his or her spouse; someone on multiple medications; and someone with multiple comorbidities. That quickly resulted in more referrals than she could case-manage, Gilbert adds. "What’s evolved is that I’m just putting out fires." For example, she’s called upon to act as a liaison when a person whose cancer has recurred appears to be headed for a hospice. Or she is asked to provide mental health support or counseling for a family that isn’t coping well, or to investigate a reimbursement failure.

Gilbert and another care coordinator do all the discharge planning on the inpatient unit and communicate with the outpatient clinic on patient care, she says. "That piece won’t go away." The question is how to identify the minimum level of care that all patients receive, and then to identify those who need more, Gilbert adds. "What we’d like to do is determine more proactively who is at risk and needs more care management, more intensity of service," she says. "We’d like to head off problems sooner."

Another issue is determining how to divide the work between Gilbert and the second oncology care coordinator in a manner that best meets the needs of all oncology patients, she notes. She says the cancer center is interested in a system where the nurse who works most closely with the patient can do an initial assessment and reassessment and, based on that, contact the other members of the care team.

"We don’t want a system where every patient is reviewed, because it’s not humanly possible," Gilbert adds. "I’m curious as to what other models people have tried and found workable."


(Editor’s note: Jackie Birmingham, RN, MS, CMAC, is a veteran discharge planning and case management consultant who is vice president of clinical design for Curaspan Inc., an application service provider based in Needham, MA, that develops technology for connectivity and information exchange between health care providers. She was named "Case Manager of the Year" for 2000 by the Little Rock, AR-based Case Management Society of America. In the response below, she offers suggestions for developing a case management model at the Regional Cancer Center.)

Casefinding and screening are hallmarks of case management, whatever the setting or patient diagnosis. In the situation described on p. 95, all the patients have met one of the cardinal criteria: They have cancer. However, further stratifying the criteria into priority categories will be necessary. One category for establishing a priority ranking is to use a functional health pattern assessment. Rather than looking at the diagnosis specifically, looking at how the patient is functioning should be helpful. Of particular importance is the patient’s ability to manage his or her own self-care needs, nutrition and activity.

A very basic screening of activities of daily living and instrumental activities of daily living will give the case manager an idea of where support is needed and what kind of support. Looking at the way Gilbert described her role, there are a few points that can be considered:

1. All patients need to be screened in some manner. Her three screening criteria are good, but she may want to look at the criteria in combination with the functional assessment. Some patients are amazing in that they may meet all three (elderly and a caregiver, multiple medications, multiple co-morbidities) and still be functional for a period of time. One cancer center uses a paper and pencil self-assessment tool when a patient is admitted to service. It is similar to other nursing-based assessment tools in that it gives a baseline of all the systems from skin to gastrointestinal, but it provides a more holistic approach. Anyone who admits the patient to the center can complete the form, and there are specific triggers for a referral.

2. Collaboration with all professional staff available to the patient needs to be developed. It appears that there are various health professionals whose roles are to provide a level of service to cancer patients. A clear delineation of role functions and where they are performed will be helpful, not only to Gilbert, but to the other professional staff. Some examples of partnerships are:

• Gilbert mentions that she is asked to provide mental health support or counseling for a family that isn’t coping. This is more appropriately done by a social worker or a clinical nurse specialist.

• The oncology care coordinators also act as liaisons with the hospice service. This may be another instance where someone in a different area can support Gilbert’s efforts. Nurses or social workers from a hospice may welcome the chance to provide coordination for their patients while they are hospitalized. The clinic staff will welcome the opportunity to get consistent feedback from the hospice on the status of their patients.

• They also are asked to do discharge planning for inpatients in the unit with 15 beds. It is important that the case manager work with the nurses and/or social workers assigned to that unit since they will probably be the ones seeing the patient’s family and coordinating care between more than one physician, both while the patient is hospitalized and when he or she returns home.

• They do case management for two clinic settings and one hospital unit. There needs to be some method of coverage for these distinct units that will eliminate the need for frequent travel, which equates to lost time.

Maria Hill, RN, MS, senior consultant with The Center for Case Management in South Natick, MA, suggests that the assignment be divided, with one person assigned to discharge planning for inpatients and the other to the clinics. Depending on the volume of patients in each unit, this is a consideration.

One recommendation for enhancing the collaborative model of case management is to develop an interdisciplinary care team. In some areas, weekly interdisciplinary meetings are held to discuss patients’ progress. Members of this type of team ideally include a hospice nurse, clinic nurse, dietitian, social worker, pastoral service representative, and a physician.

The staff from the care center, including the clinical nurse specialists for the breast and prostate cancer patients, the stem cell coordinator, and the palliative care team coordinator should regularly attend these meetings. Sometimes therapists — physical, occupational, and speech — also attend the meetings. For centers that treat children, a liaison from the school system also might be asked to attend.

These meetings should be held weekly, with a rotating chairperson, and minutes. The chairperson would be responsible for the agenda and for keeping the meetings short and to the point. If there is a patient who is in crisis, the primary caregiver should call a separate patient care conference.

My suggestion is that the care coordinators for breast and prostate cancer follow their own patients through the course of treatment, because the patient and the family need continuity of providers. Gilbert should act as consultant to these care coordinators as they take on the complete role of following the patient through the episode of illness. The functioning of the person who does the stem cell coordination can be the model for care coordination.

3. Communicating with external sources is another focus of case management.

• Contacting payers for payment questions (utilization review).

• Contacting referral sources, community agencies, transportation services.

• Working with families to determine the needs of the patient at home.

• Keeping the flow of information going between the inpatient and outpatient service. (The case manager may be the only person who knows the patient’s story.)

• Assuring all the legal duties regarding discharge planning are followed, all the ethical duties of patient choice are followed, and all standards of practice are met requires a great deal of work.

Gilbert needs a stronger network of collaborators inside and outside the organization. A look at the job from the perspective of a collaborative framework probably will give a clue as to ways to manage such a significant list of duties and responsibilities. Looking at the numbers of patients and the numbers of points of contact also will provide data for determining what needs to change.

The question Gilbert asks is a good one, and it is not unique. Outpatient centers all over the country are struggling with ways to care for patients in the new health care environment. The change in reimbursement to outpatient centers as a result of the ambulatory payment classifications, the incentives to decrease lengths of stay, and the desire of the patient and family to be at home during a critical time all add up to more pressure to manage care more efficiently. There are many like Gilbert who are struggling to do a good job in very restrictive environments.

[For more information, contact:

• Jackie Birmingham at (860) 668-7575 or by e-mail at jbirmingham@curaspan.com.]