Nelson K

Background: Concurrent care hospice allows veterans to have both disease-modifying therapy, such as chemotherapy, and hospice care. While available nationally since the VA Comprehensive End-of-Life Care Initiative 2009-2012, it has not been implemented uniformly. The palliative care team at the Minneapolis VA began to actively promote concurrent care in July of 2018. Our team includes three physicians, one nurse practitioner, social worker, hospice nurse coordinator, palliative RN, chaplain, and oncology clinical nurse specialist. We hope to share what we have learned as an interdisciplinary team and how we will continue to promote concurrent care going forward.

Results: To date, 38 patients have enrolled in concurrent care hospice through 13 hospice agencies. By chart review, we found that most patients have died (22/38 enrolled). The average length of time to death from the initial enrollment with concurrent care hospice was just over 60 days, while the average for usual hospice cancer patients is about 50 days. Two patients enrolled longer than 6 months are still living. Most patients died at home or a nursing home (19/22) while 2 died in our CLC and 1 at our inpatient hospital.

Discussion: We have identified several barriers to enrollment. Hospices have expressed concern that concurrent care is not consistent with the philosophy of hospice care and may result in withheld Medicare payments. Our hospice coordinator has invested a significant amount of time educating hospices and establishing relationships. Several agencies have declined to enroll these patients and for agencies accepting patients, the review process is more rigorous and time-consuming. Internally, our biggest partners are in oncology. We had the opportunity to present our initial data and rationale for concurrent care at a monthly oncology staff meeting. While many staff saw the benefit of adding hospice support, several physicians expressed concern that hospice patients will not receive proper medical attention for chemotherapy- related side effects. We discussed communication as the best tool to help veterans and hospice agencies understand the needs of concurrent care patients. Going forward, we hope that concurrent care becomes a normal, utilized component of best practice for our veterans.

Background: Concurrent care hospice allows veterans to have both disease-modifying therapy, such as chemotherapy, and hospice care. While available nationally since the VA Comprehensive End-of-Life Care Initiative 2009-2012, it has not been implemented uniformly. The palliative care team at the Minneapolis VA began to actively promote concurrent care in July of 2018. Our team includes three physicians, one nurse practitioner, social worker, hospice nurse coordinator, palliative RN, chaplain, and oncology clinical nurse specialist. We hope to share what we have learned as an interdisciplinary team and how we will continue to promote concurrent care going forward.

Results: To date, 38 patients have enrolled in concurrent care hospice through 13 hospice agencies. By chart review, we found that most patients have died (22/38 enrolled). The average length of time to death from the initial enrollment with concurrent care hospice was just over 60 days, while the average for usual hospice cancer patients is about 50 days. Two patients enrolled longer than 6 months are still living. Most patients died at home or a nursing home (19/22) while 2 died in our CLC and 1 at our inpatient hospital.

Discussion: We have identified several barriers to enrollment. Hospices have expressed concern that concurrent care is not consistent with the philosophy of hospice care and may result in withheld Medicare payments. Our hospice coordinator has invested a significant amount of time educating hospices and establishing relationships. Several agencies have declined to enroll these patients and for agencies accepting patients, the review process is more rigorous and time-consuming. Internally, our biggest partners are in oncology. We had the opportunity to present our initial data and rationale for concurrent care at a monthly oncology staff meeting. While many staff saw the benefit of adding hospice support, several physicians expressed concern that hospice patients will not receive proper medical attention for chemotherapy- related side effects. We discussed communication as the best tool to help veterans and hospice agencies understand the needs of concurrent care patients. Going forward, we hope that concurrent care becomes a normal, utilized component of best practice for our veterans.

Background: Concurrent care hospice allows veterans to have both disease-modifying therapy, such as chemotherapy, and hospice care. While available nationally since the VA Comprehensive End-of-Life Care Initiative 2009-2012, it has not been implemented uniformly. The palliative care team at the Minneapolis VA began to actively promote concurrent care in July of 2018. Our team includes three physicians, one nurse practitioner, social worker, hospice nurse coordinator, palliative RN, chaplain, and oncology clinical nurse specialist. We hope to share what we have learned as an interdisciplinary team and how we will continue to promote concurrent care going forward.

Results: To date, 38 patients have enrolled in concurrent care hospice through 13 hospice agencies. By chart review, we found that most patients have died (22/38 enrolled). The average length of time to death from the initial enrollment with concurrent care hospice was just over 60 days, while the average for usual hospice cancer patients is about 50 days. Two patients enrolled longer than 6 months are still living. Most patients died at home or a nursing home (19/22) while 2 died in our CLC and 1 at our inpatient hospital.

Discussion: We have identified several barriers to enrollment. Hospices have expressed concern that concurrent care is not consistent with the philosophy of hospice care and may result in withheld Medicare payments. Our hospice coordinator has invested a significant amount of time educating hospices and establishing relationships. Several agencies have declined to enroll these patients and for agencies accepting patients, the review process is more rigorous and time-consuming. Internally, our biggest partners are in oncology. We had the opportunity to present our initial data and rationale for concurrent care at a monthly oncology staff meeting. While many staff saw the benefit of adding hospice support, several physicians expressed concern that hospice patients will not receive proper medical attention for chemotherapy- related side effects. We discussed communication as the best tool to help veterans and hospice agencies understand the needs of concurrent care patients. Going forward, we hope that concurrent care becomes a normal, utilized component of best practice for our veterans.

Purpose/Rationale: Our Minneapolis VA Healthcare System (MVAHCS) team developed a self-management symptom program using the existing Annie Mobile Messaging System platform that was designed to be userfriendly for Veterans. We are currently determining which patients with advanced cancer might benefit most from the system. Here we describe early results from this program.

Background: Symptom monitoring programs using electronic communications platforms in patients with advanced solid tumors undergoing routine outpatient chemotherapy has resulted in benefits such as improved quality of life, improved survival, and reduced Emergency Room (ER) usage.

Methods: We created a symptom management protocol in conjunction with the Annie Program Team. Patients are sent text messages twice daily Monday through Friday, and they are asked to rate the following symptoms with a severity scale of 0-4 (absent, mild, moderate, severe, or disabling): Nausea/vomiting, mouth sores, fatigue, trouble breathing, appetite, constipation, diarrhea, numbness/tingling, and pain. In addition, patients are asked whether they have had a fever or not. Based on the patient response, the patient receives an automated, corresponding text back. The text may provide positive affirmation that they are doing well, give them education, refer them to an educational hyperlink, ask them to call a direct number to the clinic, or report directly to the ER.

Results: We have currently enrolled 5 patients in the program through screening new patient consults or those referred for chemotherapy education. There have not been any calls to the clinic or visits to the ER to date. Initial evaluation of the program via survey found no technology challenges and patients have been very positive about the program, including ease of use, appreciation of messages that validated when they were doing well, empowerment of self-management, and utilization of the texting advice.

Conclusions: Development and introduction of the MVAHCS Mobile Messaging System for Self-Management of Chemotherapy Symptoms has been completed. Early evaluation has not revealed any major concerns. We will continue to introduce this technology to patients undergoing chemotherapy and will further assess the feasibility and efficacy of this novel VA program.

Purpose/Rationale: Our Minneapolis VA Healthcare System (MVAHCS) team developed a self-management symptom program using the existing Annie Mobile Messaging System platform that was designed to be userfriendly for Veterans. We are currently determining which patients with advanced cancer might benefit most from the system. Here we describe early results from this program.

Background: Symptom monitoring programs using electronic communications platforms in patients with advanced solid tumors undergoing routine outpatient chemotherapy has resulted in benefits such as improved quality of life, improved survival, and reduced Emergency Room (ER) usage.

Methods: We created a symptom management protocol in conjunction with the Annie Program Team. Patients are sent text messages twice daily Monday through Friday, and they are asked to rate the following symptoms with a severity scale of 0-4 (absent, mild, moderate, severe, or disabling): Nausea/vomiting, mouth sores, fatigue, trouble breathing, appetite, constipation, diarrhea, numbness/tingling, and pain. In addition, patients are asked whether they have had a fever or not. Based on the patient response, the patient receives an automated, corresponding text back. The text may provide positive affirmation that they are doing well, give them education, refer them to an educational hyperlink, ask them to call a direct number to the clinic, or report directly to the ER.

Results: We have currently enrolled 5 patients in the program through screening new patient consults or those referred for chemotherapy education. There have not been any calls to the clinic or visits to the ER to date. Initial evaluation of the program via survey found no technology challenges and patients have been very positive about the program, including ease of use, appreciation of messages that validated when they were doing well, empowerment of self-management, and utilization of the texting advice.

Conclusions: Development and introduction of the MVAHCS Mobile Messaging System for Self-Management of Chemotherapy Symptoms has been completed. Early evaluation has not revealed any major concerns. We will continue to introduce this technology to patients undergoing chemotherapy and will further assess the feasibility and efficacy of this novel VA program.

Purpose/Rationale: Our Minneapolis VA Healthcare System (MVAHCS) team developed a self-management symptom program using the existing Annie Mobile Messaging System platform that was designed to be userfriendly for Veterans. We are currently determining which patients with advanced cancer might benefit most from the system. Here we describe early results from this program.

Background: Symptom monitoring programs using electronic communications platforms in patients with advanced solid tumors undergoing routine outpatient chemotherapy has resulted in benefits such as improved quality of life, improved survival, and reduced Emergency Room (ER) usage.

Methods: We created a symptom management protocol in conjunction with the Annie Program Team. Patients are sent text messages twice daily Monday through Friday, and they are asked to rate the following symptoms with a severity scale of 0-4 (absent, mild, moderate, severe, or disabling): Nausea/vomiting, mouth sores, fatigue, trouble breathing, appetite, constipation, diarrhea, numbness/tingling, and pain. In addition, patients are asked whether they have had a fever or not. Based on the patient response, the patient receives an automated, corresponding text back. The text may provide positive affirmation that they are doing well, give them education, refer them to an educational hyperlink, ask them to call a direct number to the clinic, or report directly to the ER.

Results: We have currently enrolled 5 patients in the program through screening new patient consults or those referred for chemotherapy education. There have not been any calls to the clinic or visits to the ER to date. Initial evaluation of the program via survey found no technology challenges and patients have been very positive about the program, including ease of use, appreciation of messages that validated when they were doing well, empowerment of self-management, and utilization of the texting advice.

Conclusions: Development and introduction of the MVAHCS Mobile Messaging System for Self-Management of Chemotherapy Symptoms has been completed. Early evaluation has not revealed any major concerns. We will continue to introduce this technology to patients undergoing chemotherapy and will further assess the feasibility and efficacy of this novel VA program.

Purpose: A multiphased QI project to increase multidisciplinary team member (social work, dietician, mental health and palliative care) visits for patients with stage IV lung cancer receiving antineoplastic therapy.

Background: The Commission on Cancer program standards require an active multidisciplinary team to meet the needs of the patient. Prior to the addition of oncology navigators at the Minneapolis VA, patients received supportive services through consults placed by the oncologist, infusion clinic nurses or patient requests. Patients were not receiving care from these disciplines for a variety of reasons, including lack of a standardized process to trigger the initiation of a consult, physicians focusing on antineoplastic therapy, lack of room space in the clinic, and the stigma associated with mental health and palliative care to the layperson. It was thought that navigators may be able to assume the role of initiating the consults and coordinating the visits because they typically meet with each patient for chemo education.

Methods: The ACCESS database used to track oncology consults was reviewed for stage IV lung cancer patients receiving parental antineoplastic treatment from January 2015 through April 2017. Patients transferring care before the completion of therapy were excluded. Charts were reviewed to determine time from consult to therapy, visits with a social worker, dietician, mental health provider and palliative care consults. A contact included any visit both inpatient or outpatient during the treatment period.

Results: There were 191 lung cancer patients, 78 met the inclusion criteria. Ninety percent (70/78) of patients had contact with a navigator. 76% of the patients received palliative care, 69% contact with a social worker, 39% received a mental health provider visit and 64% received
a consult with a dietician.

Conclusions: It is feasible for a nurse navigator to coordinate visits among multiple specialties. Coordinating the visits in the infusion center leads to increased utilization of the specialty services, freed up rooms the provider clinic and normalized the inclusion of mental health and palliative care early in the treatment course.

Purpose: A multiphased QI project to increase multidisciplinary team member (social work, dietician, mental health and palliative care) visits for patients with stage IV lung cancer receiving antineoplastic therapy.

Background: The Commission on Cancer program standards require an active multidisciplinary team to meet the needs of the patient. Prior to the addition of oncology navigators at the Minneapolis VA, patients received supportive services through consults placed by the oncologist, infusion clinic nurses or patient requests. Patients were not receiving care from these disciplines for a variety of reasons, including lack of a standardized process to trigger the initiation of a consult, physicians focusing on antineoplastic therapy, lack of room space in the clinic, and the stigma associated with mental health and palliative care to the layperson. It was thought that navigators may be able to assume the role of initiating the consults and coordinating the visits because they typically meet with each patient for chemo education.

Methods: The ACCESS database used to track oncology consults was reviewed for stage IV lung cancer patients receiving parental antineoplastic treatment from January 2015 through April 2017. Patients transferring care before the completion of therapy were excluded. Charts were reviewed to determine time from consult to therapy, visits with a social worker, dietician, mental health provider and palliative care consults. A contact included any visit both inpatient or outpatient during the treatment period.

Results: There were 191 lung cancer patients, 78 met the inclusion criteria. Ninety percent (70/78) of patients had contact with a navigator. 76% of the patients received palliative care, 69% contact with a social worker, 39% received a mental health provider visit and 64% received
a consult with a dietician.

Conclusions: It is feasible for a nurse navigator to coordinate visits among multiple specialties. Coordinating the visits in the infusion center leads to increased utilization of the specialty services, freed up rooms the provider clinic and normalized the inclusion of mental health and palliative care early in the treatment course.

Purpose: A multiphased QI project to increase multidisciplinary team member (social work, dietician, mental health and palliative care) visits for patients with stage IV lung cancer receiving antineoplastic therapy.

Background: The Commission on Cancer program standards require an active multidisciplinary team to meet the needs of the patient. Prior to the addition of oncology navigators at the Minneapolis VA, patients received supportive services through consults placed by the oncologist, infusion clinic nurses or patient requests. Patients were not receiving care from these disciplines for a variety of reasons, including lack of a standardized process to trigger the initiation of a consult, physicians focusing on antineoplastic therapy, lack of room space in the clinic, and the stigma associated with mental health and palliative care to the layperson. It was thought that navigators may be able to assume the role of initiating the consults and coordinating the visits because they typically meet with each patient for chemo education.

Methods: The ACCESS database used to track oncology consults was reviewed for stage IV lung cancer patients receiving parental antineoplastic treatment from January 2015 through April 2017. Patients transferring care before the completion of therapy were excluded. Charts were reviewed to determine time from consult to therapy, visits with a social worker, dietician, mental health provider and palliative care consults. A contact included any visit both inpatient or outpatient during the treatment period.

Results: There were 191 lung cancer patients, 78 met the inclusion criteria. Ninety percent (70/78) of patients had contact with a navigator. 76% of the patients received palliative care, 69% contact with a social worker, 39% received a mental health provider visit and 64% received
a consult with a dietician.

Conclusions: It is feasible for a nurse navigator to coordinate visits among multiple specialties. Coordinating the visits in the infusion center leads to increased utilization of the specialty services, freed up rooms the provider clinic and normalized the inclusion of mental health and palliative care early in the treatment course.