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Coleman Supportive Oncology Collaborative

In 1971, an estimated 3 million persons were living with cancer. In 2001, an estimated 9.8 million persons were cancer survivors. By January 2016, more than 15.5 million persons in the U.S. with a history of cancer were alive. The large number of persons living with cancer poses challenges for institutions and individuals to understand and address the physical, psychosocial, and economic effects of surviving cancer. After a cancer diagnosis, patients need support to manage care and achieve quality of life. Support, which considers the needs of the whole patient throughout the cancer journey, is termed supportive oncology care.

The Coleman Foundation’s vision for cancer and supportive care is that patients are fully engaged in cancer treatment and achieve the best possible outcome and quality of life. In its grantmaking, the Foundation set goals that aim to help people living with cancer from diagnosis through long-term survivorship to the end of life. The Foundation’s goal for cancer care is that patients:

  • are regularly screened for distress, psychosocial support and palliative care needs;
  • receive all appropriate services (from diagnosis through survivorship and end-of-life) from multiple, high-quality service providers that have core competencies in delivering cancer care and support; and
  • are informed and empowered by personalized care plans which are adjusted throughout cancer treatment and supportive care.

In 2014, the Coleman Supportive Oncology Collaborative (CSOC) was created to help improve supportive oncology care delivery across Chicagoland institutions. The Collaborative includes over 100 representatives from 30+: cancer treatment sites – academic, community and safety net, cancer support centers, and hospice organizations. The representatives/clinicians participate in design teams to improvement processes to deliver supportive care. These clinicians work together to implement consistent supportive care screening and alignment of services to support cancer patients. Efforts focus on helping survivors understand and access treatment; manage their ongoing physical and psychosocial issues; and engage in behaviors to optimize wellness.

During the last four years, the Collaborative has been very successful in achieving its objectives and enabling oncology care teams across ten hospital sites to identify supportive oncology needs and deliver supportive care. Having participated in process improvement efforts, sites are positioned to continue the focus on supportive oncology, while addressing a critical component of care i.e. empowering the patient / family to understand their cancer care. In 2019, the Collaborative is embarking on a new initiative, termed Coleman 4R Patient Care Sequences for Cancer and Supportive Care, to pilot an effective method to engage the care team to produce treatment plans with the whole patient at the center of care.

Coleman 4R Patient Care Sequences for Cancer and Supportive Care

The Coleman 4R Cancer Patient Care Sequences is designed to build on the American Society of Clinical Oncology’s (ASCO) guideline outlined in the “Criteria for High-Quality Clinical Pathways in Oncology”. The guideline directed at providers, calls for comprehensive pathways – care plans that incorporate multidisciplinary care. While most clinical pathways are directed at providers, multiple National Academy of Medicine (NAM) reports call for providing all newly diagnosed cancer patients and their caregivers with an individualized multi-specialty care plan that the patient and care team can use as the roadmap throughout the cancer care continuum. Per NAM, the care plan should be updated as needed during treatment and shared by patient/family and the clinical team for optimal care delivery.  

Notwithstanding these recommendations, patients rarely receive an individualized written plan at diagnosis that outlines what care they will receive during treatment, and in what order or sequence care events should occur. Through the Coleman 4R Cancer Patient Care Sequences project, the Foundation aims to address this matter at the institutional level with the patient being the beneficiary of the 4R approach. The 4R Cancer Patient Care Sequences project is intended to put a process in place that engages and empowers cancer patients with written care plans from diagnosis throughout the continuum of care. Cancer Patient Care Sequences will be developed and administered using the 4R model designed to provide the Right Information and Right Care for the Right Patient at the Right time.  4R is an innovative approach to facilitate personalized cancer care planning, as a vehicle to enable patients / families to better manage care, and to help care teams deliver “right” care to “right” patients at the “right time”, according to the care plan.  

The 4R model is a patient focused approach that results in a personalized plan, which empowers the patient to self-manage care with input from the oncology team. The model helps patients understand and manage timing and sequencing of care events across specialties; and engage caregivers and families with the care team to understand ongoing care and plan accordingly.

For this project, eight hospital sites will:   

  • Each identify two cancer types (either lung, breast or colorectal) and select oncology teams to engage in the creation and adjustment of treatment plans.
  • Inform staff of patient’s need for written care sequences/plans and educate staff on the 4R model.
  • Participate in working groups to further design/refine oncology processes, tools and training with a focus on patient materials and education.
  • Pilot, then implement patient written care sequences/plans at diagnosis, and update at transition points in care.
  • Collect quality performance metrics, including care sequence/plan metrics
  • Provide data as needed {feasibility metrics, outcomes, tool use, etc.}

The overall project objectives are to:

  • Implement written care plans/sequences at the point of diagnosis (using the 4R model) and implement updated care plans at key transitions in care.
  • Share practices between sites through collaborative working teams.
  • Develop and implement patient education materials to support understanding of written care sequences.
  • Measure impact of quality improvement of providing patients with written care plan, specifically the impact on (a) patient enablement and usage, (b) clinician satisfaction and effort, (c) impact on care timeliness and appropriateness, (d) financial impact of 4R.

Anticipated Outcomes of the 4R Project include:

  • Consistent patient care sequences provided to patients at treatment initiation and updated at specific points/transitions in care.
  • Improve patient ability to access and utilize oncology and supportive care that addresses their needs.
  • Enhance utilization of cancer support centers and other community resources across Chicagoland through integration in 4R care plans.
  • Data/Metrics available to support quality improvement and staff budgets.

The 4R project will utilize Cross Site Working Groups

Throughout the project, clinicians from eight sites will participate in working teams focused on different topics to share experiences, best practices, identify shared tools, training / education needs and overall professional networking. Working teams will focus on patient needs and include:

  • Developing tools (e.g.; patient handouts, reasons to refer, brochures, take charge cards)
  • Revising staff training and tools to support quality process improvements
  • Address issues / gaps that are faced by one or more improvement sites
  • Serve as forum for dissemination of results