Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic

PURPOSE

To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic.

METHODS

We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies.

RESULTS

Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff).

CONCLUSION

An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.

Evaluation of the efficiency of an embedded palliative nurse practitioner in an oncology clinic

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Background: We embedded a palliative nurse practitioner in 2 oncologists’ clinics in March 2014 using a reproducible training program. After one year, patients with advanced cancer receiving care in the embedded model clinics, compared to other oncologists’ clinics, were more likely to have advance care planning performed and to die receiving hospice. In order to expand the intervention to other oncologists, we evaluated the efficiency in our model of care delivery. Methods: We reviewed overall caseload and a subset of patient encounters in depth to understand how much of the NP's practice could be conducted by other staff to inform alternate clinical models of palliative care delivery in an oncology clinic. Overall time spent and time spent per task (Symptom Assessment Basic (SAB), Symptom Assessment Medical (SAM), Symptom Assessment Psychosocial (SAP), Communication Basic (CB), Communication Complex (CC)) was recorded for 16 patient encounters. We also completed 3 days of time motion study in which a trained observer tracked the NP's daily activities from minute to minute. Results: After part-time clinical participation over the first year of the program, the NP had seen 68 initial consults and 141 follow-up consults, which were potentially billable. She also had 120 encounters where she met a patient with an oncologist and 158 email or phone encounters that were not billable. Mean duration of a visit was 56 minutes (range 40-70 minutes) and about half of this time was spent on symptom assessment and communication topics requiring an MD or NP (SAM and CC), whereas half of the time was spent on topics that potentially could be covered by an RN (SAB or CB) or an MSW (SAB, SAP, CB). Time motion study revealed that a significant amount of time was spent with email correspondence and talking with other providers for care coordination. Conclusions: Palliative care is time consuming and much of the work is not reimbursed by a traditional fee for service model. Approximately half of the time spent by the NP in our embedded program potentially could have been completed by an RN or other interdisciplinary staff with training in palliative care under supervision of a physician. We plan to add an RN case management component to our model of care delivery.