Cynthia Keeney

Development of a Telehealth Intervention for Head and Neck Cancer Patients

Treatment for head and neck cancer precipitates a myriad of distressing symptoms. Patients may be isolated both physically and socially and may lack the self-efficacy to report problems and participate as partners in their care. The goal of this project was to design a telehealth intervention to address such isolation, develop patient self-efficacy, and improve symptom management during the treatment experience. Participatory action research and a review of the literature were used to develop electronically administered symptom management algorithms addressing all major symptoms experienced by patients undergoing treatment for head and neck cancers. Daily questions and related messages were then programmed into an easy-to-use telehealth messaging device, the Health Buddy(R). Clinician and patient acceptance, feasibility, and technology issues were measured. Using participatory action research is an effective means for developing electronic algorithms acceptable to both clinicians and patients. The use of a simple tele-messaging device as an adjunct to symptom management is feasible, affordable, and acceptable to patients. This telehealth intervention provides support and education to patients undergoing treatment for head and neck cancers.

Initiating and Sustaining a Standardized Pain Management Program in Long-Term Care Facilities

OBJECTIVES To identify current pain management practices in the long-term care setting; and, implement and evaluate a comprehensive pain management program in the long-term care setting. DESIGN An interventional pilot study. SETTING Community-based long-term care facilities. METHODS This study was conducted in two phases. Phase I consisted of interviewing long-term care facility administrators to ascertain current pain management policies and practices. This information was used to develop the Phase II intervention that involved collecting benchmark data, creating or modifying pain policies and procedures, implementing a pain management program and presenting educational programs. MEASUREMENTS Interviews with long term care administrators; facility and resident demographic data; chart audits for pain assessment and management data; pharmacy audits; telephone surveys. RESULTS Pain management policies and practices were inadequate prior to the study intervention. No facilities had policies or procedures that required ongoing (daily, weekly, etc.) pain assessment. Only one facility had mechanisms in place for measuring the presence or intensity of pain in their non-verbal, cognitively-impaired residents. Following the pain management program intervention, pain assessment significantly increased. and treatment for pain was provided for the vast majority of those indicating pain. All sites had a standardized pain assessment program in place one-year post-study completion. CONCLUSIONS Standardized pain management programs are critical to improving pain management in long-term care settings. Improvement in long-term care pain management can be obtained through a comprehensive pain management program that involves staff education, changes in pain policies and procedures, and identifying pain management as a quality indicator.

Palliative care case management: increasing access to community-based palliative care for Medicaid recipients.

Purpose: The purpose of this pilot project was to integrate palliative care principles and practices into the day-to-day operations of a Medicaid managed care provider. This was accomplished through the following five activities: (1) employment of an experienced palliative care nurse and social worker to serve as expert role models and consultants to the case management staff; (2) development of a palliative care training curriculum for case managers; (3) provision and evaluation of the training; (4) identification of appropriate patients, provision of palliative care case management (PCCM), and tracking of outcomes; and (5) development of a resource/reference manual for case managers. Primary practice setting: The project involved a managed care organization providing Medicaid services to patients residing in both urban and rural settings. Findings/conclusions: Expert staff was hired and modeled effective PCCM. This, as well as the training program, had significant influence on both the palliative care knowledge and attitudes of existing case managers. Involved patients demonstrated improved symptom management and satisfaction with care. Patient scenarios demonstrated desirable outcomes in healthcare utilization, and timely, appropriate hospice referrals were realized. Implications for case management practice: Integrating PCCM into the practices of a provider of Medicaid managed care can result in positive patient outcomes, improved utilization of healthcare services, and related savings for the managed care provider. Such a program can increase access to community-based palliative care for Medicaid recipients with life-threatening illnesses. PCCM can address the multiple needs of younger patients with serious illness who are not yet ready to forego curative efforts.

A longitudinal perspective of the symptom experience of patients with lung cancer near the end of life

Lung cancer patients’ unrelieved symptoms are associated with poor quality of life. Understanding their symptoms can direct interventions to enhance quality of life. This longitudinal study explored the symptoms of patients with advanced lung cancer by examining changes in symptom frequency, severity, and distress and their relationship with quality of life and functional status. Eighty patients with advanced lung cancer were interviewed within 1 month of diagnosis and at 2- and 4-month follow-up periods. Fifty percent of patients died within 5 months of diagnosis. Patients reported less symptom frequency and severity over time but no significant changes in symptom distress. Lack of energy, pain, shortness of breath, cough, and difficulty sleeping were the most common symptoms. The patients reported increased pain frequency, decreased severity in sleeping difficulties, and decreased distress related to shortness of breath. The 11 most commonly occurring symptoms were inversely related to quality of life. Five of these symptoms were negatively associated with functional status. Although symptom prevalence and severity decreased over time, symptom distress did not. Frequent and ongoing symptom assessment that includes perceived distress is paramount to direct interventions to enhance quality of life and functional status of patients with advanced lung cancer.