EXCUTIVE SUMMARY FOR NORTH PUGET CANCER CENTER1

Executive Summary for North Puget Cancer Center

Tina Hoxie, Josefina Turnek, Tamra Young

North Puget Cancer Center

Nursing 443 Interdisciplinary Care Coordination Practice Experience

Winter 2017

Western Washington University

RN-to-BSN Program

EXECUTIVE SUMMARY

  1. Introduction
  1. The Care Coordination project was conducted by a team of Western Washington University nurses in conjunction with the nurse navigator at North Puget Cancer Center at Peace Health United General Medical Center in Sedro Woolley, Washington.
  2. This cancer center is based in a designated rural access community hospital, and serves patients from Skagit, Island, San Juan, and Whatcom counties. The cancer center serves both medical and radiation oncology patients.
  3. The purpose of the partnership for Care Coordination was to observe the role of the nurse navigator as part of the cancer center’s care transition team and gain understanding in how they help the cancer patient’s transition from one health discipline to the next.
  4. From the observations that were conducted, suggestions were made to help improve the transition of cancer patients from one facility to the next.
  1. Problem Description
  1. Any cancer diagnosis tends to be complex in nature and facilitate the need for care coordination with several different medical entities. Add to this, the fact that most cancer patients also have other comorbidities, and this facilitates the need for cancer patients to receive precise and consistent care coordination.
  2. The primary demographic for this cancer center is generally patients aged 65years or greater, and is either on Medicare or Medicaid. The main type of cancer diagnoses includes lung, breast, colon, esophageal, and prostate.
  1. Process
  1. The nurse navigator identified from the radiation oncology schedule three different patients coming for their initial radiation consult that had complex care needs.Some of the patients’ care transition needs included emergency housing and financial assistance, chronic pain management of bone metastasis, and post -surgical wound care.
  2. All the students were able to meet their patients and sit in on their patient’s initial radiation oncology consult. After the consults, the students obtained medical records which they then used to develop their Care Map and Plan of Care paper. The students also visited the Saint Joseph Cancer Center(SJCC) in Bellingham to meet with the lung cancer navigator from that facility, who works closely with the navigator at North Puget Cancer Center on mutual patients. While at SJCC, the students also observed a patient receiving her first of five specialized radiation treatments known as Stereotactic Body Radiation Therapy(SBRT) for a tumor in the patient’s right lung. The students and navigator also visited Northwest Hospice and met with the admission coordinator and lead staff nurse. The Northwest Hospice visit was appropriate and necessary, as referrals to hospice are sometimes part of a cancer patient’s care transition.
  1. Key Findings
  1. As a result, from the time of observing SBRT at SJCC in Bellingham, it was noted that the coordination between the different care team members for one patients’ treatment was very in depth and took much more coordination than the students anticipated. The coordination between the lung cancer navigator and three radiation therapists, the radiation oncologist, the radiation nurse, the radiation room, and the use of the equipment needed to perform this procedure was very in depth and time consuming. In addition, prior to the procedure, a simulation has to take place in order to fit the patient with their form special mattress and bag that will be used throughout the treatments. The simulation process requires just as much care coordination as the procedure itself.
  2. The students learned that the SBRT is on average less expensive than a surgical procedure to remove a portion of their lung and is not invasive. Thus the patient has less complications, both short and long term, than if they were to have a surgical procedure. There is no recovery time or pain for a patient who receives SBRT compared to patients who have a surgical procedure. The patient may experience slight anxiety from the immobilization but nothing compared to a surgical procedure. All of these findings contribute to the strength of the communities that North Puget Cancer Center and SJCC serve.
  1. Recommendation
  • North Puget Cancer Center to formally adopt the Care Transition “Coleman Model” as currently they have no designated care transition model(“The Care Transitions Program® - Transitional Care & Intervention,” n.d.).
  • North Puget Cancer Center acquires their own equipment in order to perform the SBRT at their facility instead of referring their patients to Bellingham.
  1. Conclusions
  1. The positive component to the Care Coordination activities is the fact that there is a nurse navigator at each Peace Health cancer center to help the patient to transition from one facility to the next. The only negative component would be that North Puget Cancer Center currently does not have the ability to perform the SBRT and patients that live in Island, Skagit, or San Juan counties have to commute to Bellingham for their treatments.
  2. The Care Transition “Coleman Model” is the class reading that best suits North Puget Cancer Center based on the demographics of the patient population they currently serve(“The Care Transitions Program® - Transitional Care & Intervention,” n.d.).
  1. Reference

The Care Transitions Program® - Transitional Care & Intervention. (n.d.). Retrieved February 16, 2017, from