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Proactive Palliative Care and Palliative Radiation Model: Making MyCourse Better

Summary 
  • Need: To provide palliative care to patients with stage 4 cancer.
  • Intervention: The Emily Couric Clinical Cancer Center in Charlottesville, Virginia, has implemented a three-part program to help these patients manage their symptoms.
  • Results: The Proactive Palliative Care and Palliative Radiation Model enrolled 646 patients during its three-year funding period of 2012-2015.

Evidence-level

Promising (About evidence-level criteria)

Description

According to studies cited in the Health Care Innovation Awards (HCIA) First Annual Report, "Nearly 16% of cancer patients receive chemotherapy within two weeks of death, and 7.2% of cancer patients are admitted into the ER within one month of death." This aggressive care not only causes financial burden but can also reduce patients' quality of life, since patients' physical and emotional symptoms are often ignored in order to focus on the cancer treatment.

A better treatment for these patients is early integration of palliative care. Cancer patients who receive early palliative care are less likely to experience depressive symptoms, and they live an average of 2.7 months longer than patients receiving standard care. Plus, each patient saves an average of $4,855 with early palliative care.

University of Virginia (UVA) clinicians led by Dr. Paul Read in Radiation Oncology and Dr. Leslie Blackhall in Palliative Care wanted to develop a more integrated multidisciplinary approach to advanced care patient management. They started meeting weekly to discuss complicated patient care coordination. Through these discussions, they determined that health systems lacked informatics tools in the electronic medical records (EMR) to track patients' rapidly changing symptoms brought on by cancer progression and toxicities of cancer treatments.

Read and Blackhall also believed that they could reduce patient hospitalizations for symptom management if they could develop more rapid and convenient treatment workflows. Since UVA is a rural Cancer Center serving patients from hundreds of miles away, it was important to develop information systems that functioned remotely and treatments that could be completed in one visit.

In 2012, Read, Blackhall, and Dr. George Stukenborg and Dr. James Harris from the Department of Public Health Sciences developed a patient-reported outcomes (PRO) computer system that allowed patients to score their symptoms frequently. If symptoms worsened significantly, the computer system would trigger an alert to the CARE Track Palliative Care Team that the patient needed urgent attention.

To help stage 4 cancer patients manage their symptoms, the Emily Couric Clinical Cancer Center in Charlottesville, Virginia, developed the Proactive Palliative Care and Palliative Radiation Model with funding from a 2012-2015 Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA).

Services offered

The model is made up of three programs:

  • Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track)
  • MyCourse
  • STAT RAD

The CARE Track uses multidisciplinary care coordination to help patients manage their pain and other symptoms. A key component of CARE Track is the Supportive Care Tumor Board (SCTB), a group of experts from multiple medical fields that meets weekly to discuss complex cases and develop comprehensive care plans that are coordinated by a nurse coordinator.

MyCourse is a questionnaire focusing on a patient's clinical, functional, and psychosocial conditions. It determines which patients have the greatest need for enhanced palliative care. For example, patients are asked to report their pain levels and any anxiety or depression. While all stage 4 patients receive palliative care, MyCourse helps the medical team tailor the level of care to meet each patient's needs.

STAT RAD works to provide same-day radiation treatment for patients with metastatic, non-spinal bone cancers. Instead of a ten-session treatment, STAT RAD combines consultation, CT scans, and treatment planning into one day. For rural patients, who make up a significant portion of UVA's patients, this one-day treatment is a huge relief since it saves them time and travel expenses. To learn more about STAT RAD, please watch this 2-minute video:

There is also a similar program in place for patients with advanced heart failure.

Results

Patients using STAT RAD reported 80%-90% partial or complete pain relief by 3 months after treatment, and their quality of life improved significantly 1-26 weeks after treatment, as reported in HemOnc Today.

According to the CMS HCIA Second Annual Report, CARE Track patients experienced significantly fewer hospitalizations in the last 30 days and 7 days of life, compared to patients who received treatment before the program was implemented:

  • 60% were hospitalized in the last 30 days of life, compared to 77% of the control group
  • 27% were hospitalized in the last 7 days of life, compared to 40% of the control group

According to the CMS HCIA Third Annual Report, patients experienced a 12.9% reduction in total cost of care in the last 30 days of life, or $1,677 per patient.

Patients also reported feeling at ease with their treatment and more confident in returning to everyday activities. They and their caregivers reported that the MyCourse questionnaire was a better method for describing a patient's pain than a scale of 1 to 10.

A UVA palliative care and radiation oncology team presented their findings at the 57th Annual Meeting of the American Society for Therapeutic Radiation Oncology (ASTRO). Making MyCourse Better has also been featured in Imaging Technology News, Oncology Nursing News, and Targeted Oncology, among other online publications.

Barriers

While STAT RAD is set up to save patients time and money, the current radiation payment scheme will not support wide-scale adoption of this one-day model, instead favoring the traditional ten-day model. Changes in payment models to value-based care models may result in fewer radiation treatments being used to treat patients for palliation of bone metastases.

While the SCTB is effective in improving patients' quality of life, it is difficult to plan a meeting around 15 people's schedules. Currently, the SCTB only meets for one hour every week but hopes to find a way to expand its services and reach even more patients.

Replication

Hire a nurse coordinator who acts as CARE Track patients' main point of contact. A nurse coordinator calls or visits patients and connects them with any needed resources, like social work. UVA's nurse coordinator is assisted by an administrative specialist who, by recruiting and collecting data, allows the nurse coordinator to spend more time with patients.

Consider patient-recorded outcomes survey data for collecting information about ill patients, especially those who are older and frailer. The survey data can be longitudinally collected and displayed in electronic medical records for shared multidisciplinary use. These data can be used for:

  • Guiding patient-specific care planning
  • Alerting healthcare workers of rapidly worsening clinical status
  • Analyzing health system outcomes for quality improvement
  • Quality reporting
  • Predicting data elements for patient outcomes, like survival

Collect and monitor patient-recorded outcomes data continuously for large frail outpatient populations with high symptom burdens and/or the potential for rapid clinical decline. This real-time patient data feedback is foundational for building a responsive learning health system.

Use high-dose short or single-dose radiation regimens for patients with bone metastases. These regimens result in rapid pain relief, reduced opioid use, improved performance status, and high patient satisfaction. Such treatments are cost-effective, but they are undervalued with current reimbursement regulations due to billing edits preventing same-day billing of CT simulation, planning, and treatment delivery and due to pay-per-service or per-fraction reimbursement.

Establish a value-based billing reform model for bone metastasis palliation to recognize the value of care, not the quantity of care. Such reforms would result in highly efficient STAT RAD treatment workflows being developed by industry and implemented widely by radiation oncology centers.

Contact Information

Dr. Paul Read, Professor of Radiation Oncology
University of Virginia Department of Radiation Oncology
434.924.9288
PWR3U@hscmail.mcc.virginia.edu

Topics
Cancer
Care coordination
Hospice and palliative care
Medicaid

States served
Virginia

Date added
July 27, 2016

Date updated or reviewed
July 6, 2018


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