New primary palliative care (PC) model for community cancer clinics (CCC)


Aurora Sheboygan Memorial Hospital

Vince Lombardi Cancer Clinic

Aurora Cancer Care

Aurora Health Care


BACKGROUND: Our CCC serving a mixed rural/urban population is part of a large integrated healthcare system in Eastern WI. The closest PC specialist/team is 45 miles away at one of the tertiary care facilities. To fill this service gap we implemented a primary PC model. An initial outpatient palliative care family conference (OFC) and use of cancer nurse navigators (CNN)are hallmarks of this program.

METHODS: The VLCC, housed in a standalone facility is staffed by two medical oncologists and one radiation oncologist and has an infusion center and a full-fledged radiation oncology unit with support staff, including cancer nurse navigators, research nurses, social workers, a clinical psychologist, a pharmacist, a nutritionist, a therapy dog and a chaplain. Specialized pain management teams and services like acupuncture and hypnotherapy are readily available in the community. The patients have had access to multiple clinical trials since 2004. A team of a physician champion, a CNN and a social worker prioritized the needs and designed a program with support from system leadership. A CNN took additional training in PC. Funding from a research grant provided support for an occupational therapist (OT). Difficulties in communication was identified early as a barrier to integration of PC. OFCs were designed and conducted to discuss multiple domains of palliative care and referrals were made to different services. Pre and post enrollment surveys were administered. The following flow diagram was used (see Table).

RESULTS: In 2015, of 334 new patient visits for all stages of cancer, 32 were managed through the new PC model. Patient satisfaction scores were near 100%. Detailed methodology and data analyses will be presented.

CONCLUSIONS: A successful new model of early integration of PC that is easily replicable in communities without access to specialist PC services is presented.

New patient visit: Patient meets CNN as part of Oncology team Diagnosis refinement/staging workup Visit(s) to discuss treatments, clinical trials, initiate treatment OFC within 6 weeks: PC services ordered and coordinated Care plan communicated to patient and loved ones at OFC Meet select PC team members at each subsequent visit Home visits by CNN, OT, MD Transition to Hospice

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