Oncology Medical Home-Is Your House in Order?

January 8, 2014

Before you invite people over to your house, you prepare, right? Get things straightened up, get the food and drink ready, clean up. And you make sure everyone else in the family is aware that company is coming so that no one is half-dressed or on the way out to do some other activity. Even the most casual entertainer has to do some prep work. Personally, whenever I walk out my door, my house is in perfect order, because I always think that if I die, the state of my home will reflect on me as a person forever.

At this point, if you are an oncologist, you already have started on the path or have implemented a full-blown Oncology Patient Centered Medical Home. Notice the use of the word home here. Sounds very warm and fuzzy, not what most patients think of when they think about cancer treatment. The architects of this did not use the word center, institute, place, forum, or arena. They must have carefully chosen the word home as a description of the model of care we should be striving to deliver. That is not to say it cannot be cutting edge, state of the art, or have robust clinical trial availability.

There are excellent examples in the community of practices that have adopted this model and have had impressive and measurable results, both in improved patient utilization of the office over the emergency room (ER) and in better patient management in the office, leading to fewer calls in the off hours (who can’t support fewer calls for the on-call doc!?).

In the past, we have done a poor job of managing patient symptoms. A 2011 study tracked oncology patient use of the ER in North Carolina and found that 7.7% of cancer patients used the ER, with 45% of the visits occurring during normal practice business hours. The most common reasons for visits were 1) pain, 2) shortness of breath, and 3) nausea, vomiting, or diarrhea. This is completely unacceptable. Are we so focused on giving drugs that we can’t be bothered to manage the inevitable side effects? Shouldn’t we be arming our patients with the supportive drugs and skills to help manage their symptoms at home before they get so severe they require emergency care? And why are we sending them to the ER for those problems during office hours anyway?

You can read all the requirements and learn how other practices have implemented this concept, but my opinion is that optimum function of this model will occur when we work as a team with our entire staff. Physicians must show respect for their nurses, medical assistants, and office staff. They are critical to providing a medical home.

When I was in residency and even in the early years of practice, some physicians still expected nurses to get up and give them a seat, get their coffee, and otherwise bow and scrape to their every whim. Those were the days of chart-throwing when an order was not taken or carried out to the physician’s satisfaction. The missiles are smaller now-pens, paper clips, as actual physical intimidation will get you thrown off the medical staff-but the verbal abuse, lack of respect, and animosity between MDs and staff has to stop. One doctor I know often says, “If you wanted to fly the plane, you should have gone to pilot school.” A nurse recently left a cartoon on his desk that reads, “Be nice to your nurse, she keeps the doctor from killing you.” Can’t we all just get along and focus on the real goal, the best care of the patient?

Ultimately, the physician is the one who takes the responsibility and liability for medical care, and that is a huge stress with our very ill patients, but working as a team with a common goal can make it far easier and much more rewarding, not to mention a more pleasant working environment. I admit to getting in a snit at times when I think a nurse has asked me the same question about a decision multiple times, and I believe I've made my reasoning clear and do not plan to change it no matter how many times I'm asked. Shame on me.

On the other hand, sometimes we become frustrated and angry at a situation and not at the nurse or staff, but they may be the messenger who receives the brunt of our emotions. I recently was dealing with a homecare nurse on the phone about a particularly complicated case. I was clearly upset. I later heard the nurse felt I was mean to her. I immediately picked up the phone and called her to apologize and tell her that I have always respected her and was not in any way upset with her, it was just the frustration of trying to provide the right care for this patient. She appreciated the call, and we both felt better after venting our misery about this case.

Hospice has always been required by Medicare to provide care as a team. Indeed, every single patient is reviewed by the entire team every 14 days. And Joint Commission expects to see every discipline involved and every care plan and medication reviewed each and every time. The goal in hospice care is to provide the best care and to prevent ER and hospital admissions. This is exactly what the Medical Home is structured for, but without the formal team structure. Hospice focuses on teaching the patient and family and providing the medications in the home to address anticipated symptoms that might otherwise send a patient back into the acute care system. Oncology Homes, are you taking notes?

Your office has a team-your front desk staff sees the patient and family repeatedly, they set the tone for the visit, and they can often discern subtle changes in how patients are functioning. Medical assistants sit nose to nose with your patient every visit and get a lot of personal information that patients may not share with you-they are like personal friends to many of our patients. The same with treatment nurses, nurse navigators, nurse practitioners, and physician assistants. Listen to them. I am not saying they are always right or are making the final decision, but they can enhance your knowledge of the patient experience and they are part of the team, part of your Home. Embrace your team. Without them this whole effort is just templates, guidelines, and data. If we are going to make all this work, let’s make it a revolutionary change for the better, for the people we invite to our home.

References:

1. Mayer DK, Travers D, Wyss A, et al. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol. 2011;29:2683-8.