Improve Care Coordination in Cancer Care: 2 Key Focus Areas


When caring for cancer patients, improving care coordination in these two areas is key-and it can help reduce healthcare costs.

The good news about cancer care is there’s been “tremendous work done to transform how we diagnose and treat cancer patients,” says Barbara Tofani, MSN, RN, administrative director at Flemington, New Jersey’s Hunterdon Regional Cancer Center.

But the bad news, she says, is that patients may have to live with the impact of treatments that “haunt them physically years after we say ‘[they’re] cured.’”

Tofani discussed cancer survivorship at the Association of Community Cancer Centers (ACCC) Annual Meeting and Cancer Business Summit in Washington, DC, in March.

Many patients will continue to live years after their cancer is cured. That’s why cancer survivorship plans, which include a review of the procedures and drugs that were used, in addition to guidance on possible side effects patients may experience as a result of those treatments, are essential to their ongoing care.

Post-cancer care coordination: Ongoing communication

Patients at Hunterdon Regional Cancer Center receive their cancer survivorship plans in paper format and their oncology provider discusses those plans with them in person. The health system has also created a tab within the EHR to capture information about cancer survivorship. That means the entire oncology care team and the primary care physician know where to look within the EHR to find the information.

This is important for patients as they transition back into the care of their primary care physician. For example, a patient with breast cancer who underwent chemotherapy using Taxol (paclitaxel) may experience peripheral neuropathy, says Tofani.

Peripheral neuropathy can affect a woman’s balance, which can lead to falls. Alternatively, the patient may experience debilitating pain as a result of the condition and then live a sedentary lifestyle, which can lead to weight gain, heart disease, and diabetes, she adds.

With awareness that the patient received Taxol, her physician can pay particularly close attention to peripheral neuropathy as the woman puts years between her recovery from cancer and the rest of her life.

Tofani also highlights the importance of “warm handoffs” between healthcare providers. This is particularly important at a time when providers are dependent on technology, she says. Warm handoffs can be facilitated between oncologists and primary care physicians by care coordinators who are nurses or lay people to make the transition smooth between providers.

Care coordination while fighting the disease: Nurse navigators

Mark Krasna, MD, corporate medical director of oncology at Wall Township, New Jersey-based Meridian Health System, also discussed care coordination for cancer patients at the ACCC annual meeting.

He emphasizes the role of a nurse navigator who can communicate with all specialists-from the radiation oncologist to the oncologist to the surgeon to the primary care provider-engaged in a patient’s care. While playing a pivotal role as a point of contact for questions from family members, the nurse navigator can also ensure that consensus is reached across all providers in terms of the best approach to care.

Care coordination is attractive to payers because it can lead to fewer unnecessary X-rays and MRIs, says Krasna. Also, involving a care coordinator can lead to fewer hospital admissions related to complications such as dehydration, which many patients experience.

He notes that patient satisfaction is typically over 90% at facilities that provide good care coordination. Those high patient satisfaction scores can also translate to more referrals in the future, adds Krasna. That’s because those satisfied patients will tell friends and family members about their positive experiences.

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