Shared Decision Making

Michele O’Brien RN,MSN,ACNS-BC, BAMinnesota OncologyThoracic Oncology Clinical Nurse Specialist

Potential Barriers to Timely Health Care

Financial Health care system Patient and family understanding of

disease and goal of treatment Social support Fear Transportation Cultural

National Institutes of Health Analysis

Growth and aging of the U.S. population Medical expenditures for cancer in the

year 2020 are projected to be $158 billion (in 2010 dollars)

27 % over 2010 Analysis is online, 1/12/2011, in the

Journal of the National Cancer Institute

Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. Projections of the Cost of Cancer Care in the United States: 2010-2020. Jan 19, 2011, JNCI, Vol. 103, No. 2.

National Institutes of Health Analysis

Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, and Brown ML. Projections of the Cost of Cancer Care in the United States: 2010-2020. Jan 19, 2011, JNCI, Vol. 103, No. 2.

Guided Care Reduces Cost

Multi-site, randomized controlled trial of Guided care

Involved 14 primary care teams of 49 physicians, 904 older patients with chronic conditions

8 locations in Baltimore, Washington Guided care model is a proactive,

evidence based health care provided by a physician-nurse team

Am J Manag Care. 2009;15(8):555-559)

Guided Care Reduces Cost

Using insurance claims-compared health care services

Guided care patients had 24% fewer hospitalizations 37% fewer skilled nursing facility stays 15% fewer ER visits 29% fewer home care episodes• Representing an annual net saving of $75,000

per nurse or $1,364 per patient

Am J Manag Care. 2009;15(8):555-559)

How does SDM translate to oncology?

Complex Care Management

Quality of care and medical services for seriously ill patients are key elements in the ongoing debate over health care reform in the US

Pro-active Approach

Aimed to reduce physical and psychological distress includes: Interdisciplinary programs Patient navigation Survivorship/SDM QOL measurements

Quality of Life Predicts Lung Cancer Survival

ROTG 9801 QOL study included patients with locally

advanced NSCLC Study of 239 patients found those with

QOL score less than median 66.7 had 69% higher death rate

Married patients and those with partner had the highest QOL scores

Oncology Times: Volume 29 (24)25 December 2007

Early Palliative Care

Study performed at Massachusetts General Hospital, Boston

Eligible patient enrolled within 8 weeks after diagnosis

1:1 randomization Early palliative care resulted in survival

Prolonged by 2 months Clinical improvement QOL and mood

N ENGL J MED 363;8 August 19, 2010

Shared Decision Making Model (SDM)

Ongoing process in oncology care Important to create flow of

communication between Physicians, patients and Advanced Practice Nurse

Patient’s need to be evaluated throughout their cancer journey

Minnesota Oncology Survivorship Program

Formalized SDM into survivorship program Multidisciplinary approach Goals of program to improve:

Clinical outcomes Improve overall QOL Real time evaluation of patients QOL Early interventions Supportive Emotional Functional Patient participation in care Access to advocacy Decrease hospitalizations

Decision Support/Aids

Shared Decision Making Collaborative Conversation Map

Build RapportPlanningTailor

Intervention

Reassess

Copyright © 2010 ICSI All Rights Reserved1Makoul G, Clayman M, An integrative model of shared decision making in medical encounters, Patient Education and Counseling, 60 (2006) 301-312

Patient Presentation

69 year old female History of smoking 1pack/day for 30

years quit 6 years ago Married and works full time Pre-operative chest x-ray for knee

surgery revealed abnormality Asymptomatic for any lung cancer

symptoms

Planning Phase

Diagnostics tests revealed masses in left upper and lower lobe

Left upper lobe lung biopsy was positive for lung cancer

Discussion with surgeon about diagnosis and treatment options

Building Rapport

Surgeon provided information Diagnosis Prognosis Surgery

Clinical Nurse Specialist (CNS) met with patient and husband to offer education and support

Tailored Intervention

Formal visit with CNS formal Reviewed understanding of the

diagnosis and treatment options Evaluated physical concerns

Recovery from knee surgery What to expect from lung surgery

Emotional concerns Fear of death and unknown

Decision Support Aids

CNS Identified resources

Educational materials regarding lung cancer, surgery

Patient and husband verbalized understanding Risk and benefits of surgery

Provided patient with community resources Lung cancer support group

Identified that if patient had a health care directive

Identified who was her support system

Reassess

Patient’s post operative course was uncomplicated

Issues with pain management post operatively

Physician discussion if this represented two separate primary tumors (Stage IB) or a spread LUL and LLL tumors Overall stage determined to be Stage IIIB

Planning Phase

After patient recovered from surgery

Met with oncologist to discuss Prognosis Role of chemotherapy to decrease

recurrence risk Oncologist recommended

chemotherapy

Building Rapport

Discussion with Surgeon and Oncologist to review recommendations

CNS met with patient and husband

Tailored Interventions

CNS formal visit Evaluated recovery from surgery Referred patient to respiratory therapy Reviewed

Understanding of pathology results and stage of cancer

Chemotherapy treatment plan Identified concerns about

Next phase of treatment Discussed fears

Decision Support Aids

CNS Identified resources

Written educational materials regarding chemotherapy

Educational resources in clinic Chemotherapy class

Reassess

Patient followed during chemotherapy Symptom management Coping skills

Completed chemotherapy

Planning

Patient met with oncologist to discuss: Role of maintenance therapy Follow up plan

Patient will start Maintenance therapy couple months

after chemotherapy

Tailored Interventions

CNS formal visit Evaluated recovery from chemotherapy Discussed patients concerns about

maintenance therapy Feeling stronger/ more energy Side effects are resolving Trying to understand her “new normal”

Patient expressed Wants to do everything she can to keep the

cancer from coming back

Decision Support Aids

CNS Identified resources

Written materials regarding maintenance therapy

Reassess

Close observation and counseling regarding clinical management of therapy

Patient experienced Several side effects from maintenance therapy Palliative care

Patient continues on therapy CNS formal visit

Referred patient to Complementary Therapy Center Guided imagery Massage

Offered counseling regarding the emotional impact the side effects have had

Evaluation of Patient Experience

Improved communication Patient-physicians Patient-nurse Patient-family

Early interventions Saved hospital re-admission Increased patient satisfaction

Patient’s Feedback

“The reality of today’s medical care is that physicians do not have the time to sit with a patient and deal with the emotional aspect of a horrible disease.”

“I felt like part of the decision making process.”

“The survivorship program helped me regain my mental health and that lead to my physical recovery.”

Questions?

Thank You for your time!