DISCUSSION QUESTIONS 1. At each of the steps proposed, what are the current barriers and opportunities?

2. What resources do clinics have to respond to oncology patient needs outside of the ED?

3. How can these initiatives be funded?

4. Are there new value or outcome-based approaches to help fund these interventions?

5. Could providers bill for telehealth to fund the call line?

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

HOSPITALIZATIONS & EDUSE DURING TREATMENT

VISION STATEMENT: Supplying cancer patients with proactive and responsive tools and support ensures that patients experiencing worsening symptoms can receive the care they need, and the care their providers prefer, without unnecessary hospital visits.

INTERVENTION WORKING GROUP

INTERVENTION PROPOSAL

Clinics can develop one or more of these tools, based on clinic resources, to help patients with common symptoms related to cancer treatment find suitable care. These tools are placed in order of ease of implementation.

SYMPTOM SELF-MANAGEMENT TOOLS FOR PATIENTS

TELERESOURCE ONCOLOGY URGENTCARE CAPACITY

Pre-weekend assessment

Symptom self-management plan(s)

Online/e-resources

Outgoing: actively reaching out to patients at key timepoints

Incoming: 24/7 centralized, oncology-staffed call line

In clinic

Ability to give IV fluids

Regional shared capacity

Symptom Management for Cancer Patients in Treatment

Symptom Self-Management Tools Teleresource Oncology Urgent Care

• Check in with patients before the weekend; review common symptoms and how patients can respond

• Medication reconciliation

• Provide information on possibilities and intensity to expect

• Target highest risk patients

• Utilize standard protocols of care (i.e. pain meds, antiemetic)

• Develop consensus-approved, standardized content for most common symptoms

• Centralized line needs to be clearly advertised• Staffed by oncology-trained professionals with access to appropriate medical staff• Standardized care pathways to triage or treat patients• Provide Outgoing and Incoming call support • Outgoing: Proactively reach out to patients at key timepoints (ex: 3 days after chemotherapy) • Incoming: Available call line for patients with worsening symptoms

In Clinic• Modify staffing plans to allow time for medical staff to respond to urgent care needs• Ensure that cancer patients are receiving CSF (colony-stimulating factors) according to Choosing Wisely guidelines to reduce febrile neutropenia• Assess possibility of 24/7 accessAbility to give IV fluids• As possible, reserve chairs in infusion centers for emergent and urgent care of patients• Extend hours of infusion centers to weekends and eveningsShared regional cancer-specific urgent care capacityCan help:• patients who are not near their treating clinic• smaller clinics • clinics with limited hours

CONTINUED

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

HOSPITALIZATIONS & EDUSE DURING TREATMENT

INTERVENTION WORKING GROUP

CONTINUED

REFERENCES1. The Advisory Board Company. Readmission Reduction Toolkit. (2014). Retrieved from website: https://www.advisory.com/research/cardiovascular-roundtable/studies/2014/readmissions-reduction-toolkit

2. The Advisory Board Company. Study: The drop in readmissions isn't because of more observation stays. It's real. (2016). Retrieved from website: https://www.advisory.com/daily-briefing/2016/02/26/study-drop-in-readmissions-i snt-because-of-more-observation-stays

3. Anderegg, S. V., Wilkinson, S. T., Couldry, R. J., Grauer, D. W., & Howser, E. (2014). Effects of a hospital-wide pharmacy practice model change on readmission and return to emergency department rates. American Journal of Health-System Pharmacy, 71(17), 1469-1479. doi:10.2146/ajhp130686

4. Bartz, N., Fuller, D., & Conway, L. (2013). Urgent Care for Cancer Patients Four Tactics to Reduce ED Visits and Hospitalizations. The Advisory Board. Retrieved from https://www.advisory.com/ Research/Oncology-Roundtable/Studies/2014/Urgent-Care-for-Cancer-Patients

5. Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: a review and synthesis of best practices. Journal of American Medical Association Internal Medicine, 174(12), 1994-2003. doi:10.1001/jamainternmed.2014.5271

6. Bowles, K. H., Hanlon, A., Holland, D., Potashnik, S. L., & Topaz, M. (2014). Impact of discharge planning decision support on time to readmission among older adult medical patients. Professional Case Management, 19(1), 29-38. doi:10.1097/01.PCAMA.0000438971.79801.7a

7. Delate, T., Chester, E. A., Stubbings, T. W., & Barnes, C. A. (2008). Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. Pharmacotherapy, 28(4), 444-452. doi:10.1592/phco.28.4.444

8. Dudas, V., Bookwalter, T., Kerr, K. M., & Pantilat, S. Z. (2001). The impact of follow-up telephone calls to patients after hospitalization. American Journal of Medicine, 111(9b), 26s-30s.

9. Frellick, M., Vassall, J., Perna, B., & Short, G. (February 2016). WSMA Reports: When more than ‘meh’ is needed. Get out the paddles: State’s health pulse irregular to failing. Retrieved from https:// www.wsma.org/doc_library/ForMembers/WSMAReports/WSMA%20Reports%2002%20February16.pdf

10. Goyal, R. K., Wheeler, S. B., Kohler, R. E., Lich, K. H., Lin, C. C., Reeder-Hayes, K., & et al. (2014). Health care utilization from chemotherapy-related adverse events among low-income breast cancer patients: effect of enrollment in a medical home program. North Carolina Medical Journal, 75(4), 231-238.

11. Hunis, B., Jose Alencar, A., Castrellon, A. B., Raez, L. E., & Guerrier, V. (2016). Making steps to decrease emergency room visits in patients with cancer: Our experience after participating in the ASCO Quality Training Program. Paper presented at the 2016 ASCO Quality Care Symposium, Phoenix Arizona. http://meetinglibrary.asco.org/content/160965-181

12. Jack, B. W., Chetty, V. K., Anthony, D., Greenwald, J. L., Sanchez, G. M., Johnson, A. E., & et al. (2009). A Reengineered Hospital Discharge Program to Decrease Re-hospitalization: A Randomized Trial. Annals of Internal Medicine, 150(3), 178–187.

13. Koehler, B. E., Richter, K. M., Youngblood, L., Cohen, B. A., Prengler, I. D., Cheng, D. and Masica, A. L. (2009), Reduction of 30-day post-discharge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. Journal of Hospital Medicine, 4: 211–218. doi: 10.1002/jhm.427

14. Kuntz, G., Tozer, J. M., Snegosky, J., Fox, J., & Neumann, K. (2014). Michigan Oncology Medical Home Demonstration Project: first-year results. Journal of Oncology Practice, 10(5), 294-297. doi:10.1200/jop.2013.001365

15. Legrain, S., Tubach, F., Bonnet-Zamponi, D., Lemaire, A., Aquino, J. P., Paillaud, E., & et al. (2011). A new multimodal geriatric discharge-planning intervention to prevent emergency visits and re-hospitalizations of older adults: the optimization of medication in AGEd multicenter randomized controlled trial. Journal of the American Geriatrics Society, 59(11), 2017-2028. doi:10.1111/j.1532-5415.2011.03628.x

16. Lund, J., Pearson, A., & Keriazes, G. (2015). Identification of Risk Factors for Chemotherapy-Related 30-Day Readmissions. Journal of the National Comprehensive Cancer Network, 13(6), 748-754.

17. Meisenberg, B. R., Graze, L., & Brady-Copertino, C. J. (2014). A supportive care clinic for cancer patients embedded within an oncology practice. Journal of Community Support Oncology, 12(6), 205-208.

18. Naylor, M., Brooten, D., Jones, R., Lavizzo-Mourey, R., Mezey, M., & Pauly, M. (1994). Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Annals of Internal Medicine, 120(12), 999-1006.

19. Purdy, S., Paranjothy, S., Huntley, A., Thomas, R., Mann, M., Huws, D., & et al. (2012). Interventions to reduce unplanned hospital admission: a series of systematic reviews: Final Report June 2012. National Institute for Health (UK). Research Retrieved from http://www.apcrc.nhs.uk/library/research_reports/documents/9.pdf

20. Reid, R. J., Coleman, K., Johnson, E. A., Fishman, P. A., Hsu, C., Soman, M. P., & et al. (2010). The Group Health Medical Home at Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers. Health Affairs, 29(5), 835-843. doi:10.1377/hlthaff.2010.0158

21. Schnipper, J. L., Kirwin, J. L., Cotugno, M. C., Wahlstrom, S. A., Brown, B. A., Tarvin, E., & et al. W. (2006). Role of pharmacist counseling in preventing adverse drug events after hospitalization. Archives of Internal Medicine, 166(5), 565-571. doi:10.1001/archinte.166.5.565

22. Yu, S. (2016). How the Cleveland Clinic saves cancer patients' lives in the ED. Retrieved from The Advisory Board Company website: https://www.advisory.com/research/oncology-roundtable/oncology-rounds/2016/01/cleveland-clinic-febrile-neutropenia-protocol

23. Zuckerman, R. B., Sheingold, S. H., Orav, E. J., Ruhter, J., & Epstein, A. M. (2016). Readmissions, Observation, and the Hospital Readmissions Reduction Program. New England Journal of Medicine. doi:doi:10.1056/NEJMsa1513024

WORKING GROUP PURPOSEExplore intervention protocol(s) to decrease the rate of avoidable hospitalizations and emergency department (ED) use by cancer patients during treatment.

KEY POINTS• A combination of factors contribute to cancer patients seeking care in the ED:

• Limited clinic hours

• Patient understanding of symptom self-management

• Patient access to urgent care resources

• Many oncology clinics may not have the necessary resources to provide urgent care

DATA REVIEWEDBased on HICOR data, some of the most frequent diagnoses during inpatient and ED visits may be preventable.

Initial Analysis:

N=Unique non-cancer diagnosis codes recorded during an inpatient stay or emergency department visit 90 days from treatment initiation

Sample=4,473 Patients; 12% had an inpatient stay; 11% had an emergency department visit

CONSENSUSRecognizing varying clinic characteristics (rural or urban; low or high volume) the working group recommends a step-approach to symptom management in order to prevent unnecessary ED use for frequent symptoms.

14%

12%

10%

8%

6%

4%

2%

0

Most Frequent Non-Cancer Diagnosis Codes 90 Days Post Chemo/Radiation Initiation

Neu

trop

enia

Pain

Vasc

ular

cath

eter

Feve

r

Pleu

ral

effus

ion

Resp

irato

ryfa

ilure

Resp

irato

ryab

norm

aliti

es

Pneu

mon

ia

Lum

p in

che

st

Nau

sea/

vom

iting

Mal

aise

/fa

tigue

Sync

ope/

colla

pse

Inpatient stay (n=713)

ED (n=300)