Sabrina Q. Mikan

A Pilot Study of a Cognitive-Behavioral Intervention for Breast Cancer Survivors

Purpose/Objectives: To test combining a group intervention to build self‐efficacy for using compensatory strategies and lifestyle adjustments with brain‐training practice to improve cognition. Design: A quasiexperimental design. Setting: Texas Oncology, a community oncology practice in Austin. Sample: 20 women aged 35‐65 years, who had finished chemotherapy at least three months before the study, were within five years of completing all treatment, and had self‐reported cognitive concerns. Methods: Six group sessions to build self‐efficacy for using compensatory strategies, along with other health behaviors that affect cognitive performance, were combined with practice on a computer‐based training program. Female breast cancer survivors were recruited through flyers, mailings, and personal contacts. Main Research Variables: Cognitive performance, cognitive concerns, cognitive/memory strategies, fatigue, emotional distress, sleep disorders, and quality of life. Findings: Participants reported that the intervention was useful in building cognitive abilities. Although scores on performance tests did not increase, ratings of cognitive concerns, fatigue, emotional distress, and sleep disturbance decreased significantly. Use of cognitive/memory strategies increased significantly. Conclusions: This pilot study demonstrated the feasibility of combining a group intervention with brain‐training practice. A larger randomized trial would afford a more rigorous test of efficacy. Implications for Nursing: A growing body of evidence regarding potential interventions to address survivors’ cognitive problems exists. Nurses should counsel breast cancer survivors about fatigue, sleep deprivation, and emotional distress, as well as the effects of cancer treatment on cognition.

Advanced practice providers and survivorship care plans.

70 Background: The American College of Surgeons mandate in 2012 challenged organizations to create and develop quality survivorship care programs. The NCCN and Commission on Cancer set the standard for quality psychosocial care recognizing distress as part of the cancer continuum. In order to meet this challenge, community cancer care organizations are incorporating delivery of survivorship and psychosocial care into the Advanced Practice Provider (APP) role. APPs include Physician Assistants (PAs) and Advanced Practice Nurses (APNs). We describe the development and feasibility testing of an APP-led survivorship program in a large network of community oncology practices. METHODS A descriptive study design was used with ten practices participating in the implementation of a structured APP-led survivorship program. The goals of each survivorship visit were to: review recommendations for care and healthy lifestyle behaviors, review surveillance recommendations, and to reconnect patients with their primary care providers. Nineteen APPs in the study site practices offered survivorship management between October 2012 and May 2015 to female breast and colon cancers at all stages. RESULTS Study sites used structured process maps to identify and refer patients to survivorship visits. Evaluations of additional referral strategies are ongoing. Participating APPs reported high self-efficacy in delivering survivorship care plans and high patient satisfaction following visits. All female breast or colon cancer patients, regardless of stage at diagnosis, attended the appointment and received a complete care plan based upon the ASCO Survivorship Care Plan. Surveillance education was provided specific to diagnosis utilizing the NCCN guidelines delivering person-centered care. Visits lasted an average of 60 minutes and were billable as counseling and coordination. CONCLUSIONS Patients diagnosed with breast or colon cancer make up the largest majority of cancer survivors. This project reveals that an APP-led survivorship program is feasible and can help to meet the ASCO and NCCN challenge of providing survivorship care to this large population.

Improvements in communication and engagement of advance care planning in adults with metastatic cancer through a targeted team approach.

14 Background: Advance care planning (ACP) continues to be a vital part of comprehensive, person-centered cancer care. A large community oncology practice performed a targeted approach to improve patient engagement of ACP. A process improvement project with three goals was set: increasing ACP referrals, ACP counseling visits and completed Values Assessment (VA) instrument. A leadership team consisting of practice director, physician, nurse manager, and nurse practitioner was developed with ownership of roles and responsibilities. METHODS The ACP leadership team outlined workflows to be tested, followed by evaluating outcomes of each goal over 107 days. Barriers and challenges were identified; ACP education was taught to staff. NP and RNs introduced ACP to patients during ChemoTeaching. Eligible patients were identified weekly by infusion RNs on C1D1, and patients were given the VA. Desk RNs would speak with patients on C1D2 to review symptoms and VA responses. RNs would offer ACP visits to patients. Referrals were made for patients to have one-on-one counseling with NP. Staff was educated about EMR documentation by RN manager. Weekly team phone meetings were held to discuss project status. RESULTS During the first 53 days of the project, 20 patients were identified at C1D1, 5 VA were completed and 15 ACP visits occurred. After evaluation, weekly communication with clinical staff increased to daily huddles. Daily communication allowed for RNs to identify C1D1 patients and communicate to the full team. During the second 54 days, 94 patients were identified at C1D1, 46 VA were completed, and 27 ACP visits occurred. A 5-fold increase occurred in patient identification; a 9-fold increase in VA completion occurred, and approximately 2-fold increase occurred in ACP counseling. CONCLUSIONS By developing a focused and concerted process on ACP, the cancer center was able to show that patient engagement in the ACP process markedly improved. A navigation process for identifying patients who would benefit from ACP counseling was vital in increasing in the counseling visits. Continual quality improvement by refining processes in the ACP program will benefit patients.

Patient-centered conversations: Advance care planning values in the adult oncology population.

147 Background: Over the past 2 years a structured advance care planning program (ACP) has been created, piloted and is evaluated monthly at 10 Texas Oncology practices. This program is a systematic process for assessing patient values, is physician supported and is delivered by advanced practice providers at each site. Patient values and quality of life are at the center of the conversations, enhancing patient-centered care and communication with their oncology providers. Targeted patient populations include metastatic lung, pancreatic and colon cancers. METHODS Over the past 14 months, 332 patients engaged in ACP in ten sites. Descriptive statistics for each site were calculated and examined to explore 1) ACP counseling sessions, 2) number of Patient Values questionnaires completed, 3) frequency of code status documentation in the health record, and 4) hospice enrollment for both the targeted and all metastatic populations. RESULTS A three month review revealed the ACP work within all metastatic populations at the ten sites. Targeted population totals showed continued increase in the percentages of patient ACP engagement at each site. For the practice as a whole, and the targeted population, 9-23% of patients have received an ACP counseling visit. There have been 149 completed Patient Values questionnaires. In the electronic health record, there are 2,233 (24%) patients who have a documented code status. A range of hospice enrollment from 8-28% in the targeted populations has continued to improve hospice length of stay. CONCLUSIONS The patient is invited to explore their treatment options, their personal values and the completion of the advance directive documents. Truthful conversations are critical between patient and provider in order to create a meaningful treatment plan, and to allow the patient to gain understanding about their options. Early palliative care referrals are integrated into each session for symptom management through local partnerships with palliative care physicians. Education regarding life-sustaining interventions help the patient determine their choices for medical care. Having ACP counseling is important at any stage of health and particularly within life-limiting disease.

Midlevel provider utilization within a large community oncology network.

282 Background: The Association of American Medical Colleges (AAMC) reports that 56% of Oncologists work with midlevel providers (MLPs). MLPs include physician assistants (PAs) and advanced practice nurses (APNs). Within our large network of community oncology practices,there are 241 MLPs (88 PAs and 153 APNs). The MLP role encompasses the continuum of care beginning with genetic risk assessment throughout treatment, health promotion teaching, survivorship management and advance care planning (ACP) services. METHODS We used an online survey to elicit self-reported proficiency in eight core health care delivery roles. A 52 item, 5-point Likert scale (novice, advanced beginner, competent, proficient, expert) survey was sent in March 2013 to all MLPs. RESULTS Of all MLPs (n=241) invited to participate, 103 (43.5%) responded anonymously. Over half of all MLPs reported feeling proficient in the areas of collaborating with multi-disciplinary teams to formulate a plan of care (50.4%), facilitating patient and family decision-making in treatments, symptom management and end-of-life care (53.3%), and providing information to patients and families to facilitate adherence to cancer treatments and supportive care (54.2%). Secondly, the MLPs were confident in their ability to provide proficient care in health assessment through physical exam (46.6%), disease progression signs and symptoms (44.7%), and incorporating resources that meet diverse needs of the patients into the planning and delivery of care (52.3%) areas. Finally, the areas where MLPs reported feeling less than proficient were in specialty areas such as survivorship (34.2%) and genetics (34.2%). Also noted, for 45.7% of respondents, ACP was performed only 1-20% of their time. CONCLUSIONS Self-assessment is one form of measurement that allows the individual provider to identify their strengths and weaknesses. It is important so that educational resources can be created, tested, and shared amongst providers to continue to improve their confidence and care delivery. Ongoing work in developing strong tools for survivorship visits, advance care planning, and genetic counseling within our network, is recognized as an imperative part of advancing PA and APN skills and quality patient care.