Rethinking current models of survivorship care: Addressing needs of oncology patients with multiple chronic conditions

I was intrigued by the article below. It highlights the need for a specialized and coordinated team to facilitate clinical care for our cancer patients that have multiple chronic conditions. As a survivorship provider that engaged with patients at time of diagnosis, I experienced the impact of partnering with PCPs on the management of chronic conditions and with creating a proactive plan of care. This plan addressed issues that could impact a patient's ability to complete treatment, reduced treatment related effects thought proactive care and identified issues early for intervention. I hope you appreciate the summary of the article provided and my thoughts at the end.

Overview of Team complexity and care coordination for cancer survivors with multiple chronic conditions: a mixed methods study?

Dana Verhoeven1,2 · Michelle Doose3? · Veronica Chollette1? · Sallie J. Weaver

Journal of Cancer Survivorship https://doi.org/10.1007/s11764-023-01488-w

Background

Currently, clinical care guidelines and strategies to comprehensively coordinate cancer care for people with multiple chronic conditions (MCC) are absent. Research indicates that chronic disease management for common conditions like hypertension and diabetes may decrease following a cancer diagnosis.

Limited research to date has examined this hypothesis and questions remain regarding how patients and their healthcare teams manage, prioritize, and coordinate both the cancer and pre-diagnosis chronic conditions among cancer survivors with MCCs.

Study

Cancer survivors completed an online survey (N=441) of which 12 participated in an interview. Team complexity was operationalized based on team size, clinician specialties, and health system affiliation. Kilpatrick’s Patient-Perceptions of Team Effectiveness (PTE) questionnaire measured team effectiveness. Constant comparative method was used to identify care coordination challenges and facilitators from interviews. ?Please note that survivorship coordination from the day of diagnosis was not included as a team model in this study.

Results/Findings

Most participants’ healthcare teams were categorized as being moderately complex (49%).

Cancer care delivery uses a multiteam system approach, where several different care teams from surgical, medical, and radiation oncology often work together to develop treatment plans and coordinate patient care activities. Cancer survivors with MCCs often have larger and more complex healthcare teams, or multiteam systems, to simultaneously manage their cancer care and other chronic conditions, including component teams from primary care, cardiology, endocrinology, or pulmonology as well as social workers or patient navigators.

The most common healthcare team composition across all study participants included oncology care providers, primary care providers, and at least one medical specialist (54%). A quarter of all participants reported having a navigator/social worker/coordinator on their care team.

Closed loop communication, where each provider reviewed concerns and followed-up for other conditions, also demonstrated to participants that the healthcare team communicated with each other and was aware of all health conditions

Some of the interviewees viewed themselves as the communicator for their care team, having to “message [the doctors] and let them know what’s going on or ask different questions. It’s kind of like repeating stuff over again and letting them know what’s going on with me right now.” Some participants also stated that their healthcare team did not communicate with each other despite being located within the same health system and having access to the same medical records. Some were not sure if their healthcare team ever communicated with each other.? Several interview participants reported that “none of the doctors were on the same page” and received conflicting opinions and information from providers from different disciplines that either led them to seek care out-of-network or created chaos among their healthcare team.

The patient-family focus subscale was the most negatively viewed team process with 54% of survey participants and 25% of interviewees rated it low, meaning participants did not view themselves as a having a role to play in their healthcare team, their contributions were not valued by the healthcare team, and providers did not work with their families to solve patient care issues. Challenges included difficulty finding specialists, advocating for one’s health or care needs when care coordination mechanisms or modalities were absent, not having concerns, needs, and preferences valued particularly when concerns or preferences related to emotions, finances, employment, and time burden. Participants also identified themselves as the “referee” for conflicting care recommendations or decisions among their care team.??

Conclusion

Overall, cancer survivors rated the effectiveness of their healthcare teams as high, with most participants rating care coordination high. At the same time, interview participants shared examples of difficult experiences working with their healthcare team, as well as challenges navigating coordination among different specialists. This mixed method study illustrates that care team composition varies from low to high complexity among cancer survivors with MCC and is associated with perceived team effectiveness where high complexity teams had lower team effectiveness

However, team complexity was not directly associated with outcomes of care, which may indicate that how the team functions matters more than who is on the team,

In addition to these domains, our study highlighted the importance of care delivery structures and trust in facilitating teamwork

While the presence of a navigator or care coordinator did not significantly impact patients’ perceptions of teamwork in our study, prior research suggests that having a navigator on the care team, who can serve as a mediator between the patient and their care team as well as a connector between the multiple different specialists and associated teams involved in the larger multiteam care system, can reduce the burden placed on patients.

Further research is needed that integrates health system leaders, providers, and patients’ perspectives to understand how best cancer care teams and other specialty care teams can co-manage and prioritize MCC, especially within our fragmented healthcare system.

Improving teamwork in multiteam systems offers one way to leverage the expertise of multiple specialties to deliver integrated, patient-centered care for cancer survivors.

Study Limitations

• Convenience sample of self identified cancer survivors recruited through two online survey platforms
• These findings should be cautiously interpreted as the study was not powered to detect subgroup differences
• Racial and ethnic diversity of participants was low
• Survey was cross-sectional and cannot be used to assess causality.?
• Potential for recall bias in responses since one-third of the participants were more than 5 years out since their cancer diagnosis.?

Personal Observations?

I appreciate that this study is focused on cancer patients with multiple chronic conditions.? These individuals present with more complexity and make up a significant percentage of those seen in US cancer centers.? These individuals depend on effective coordination including closed loop communication for optimized care.? In addition, in this study only 25% of patients had a navigator/social worker/coordinator on their care team to assist with coordination.?

When a knowledgeable and effective care team is not in place, the survivors’ and their care partners’ distress can increase as they feel the dysfunction of uncoordinated care and are put in the position of trying to navigate the system on their own. Most importantly, this also leads the patient/care partner dyad from feeling disenfranchised from participating in their care.?

We should be exploring the ?TEAM Medicine model as a way to optimize resources for care coordination and decrease provider burnout.? Active treatment teams are put in the position of treating cancer along with its impact on pre-existing comorbidities and coordinating communication.? There are additional consequences beyond poor care coordination and communication due to the lack of a supportive care team led by a provider (trained in survivorship, supportive care and wellness) beginning at time of diagnosis.? Per the article below, current models of survivorship care that begin after cancer treatment has ended may create harm, excess suffering, and lost opportunities for toxicity mitigation, disability prevention, participation in cutting-edge research, and long-term health optimization. In addition, having this team in place starting at time of diagnosis serves to connect oncology, primary care, subspecialists, supportive care clinicians and programs, researchers, and patients and caregivers

Engaging TEAM Medicine in Patient Care: Redefining Cancer Survivorship From Diagnosis

Authors: Catherine M. Alfano, PhD u, Kevin Oeffinger, MD , Tara Sanft, MD , and Brooke Tortorella, MPH AUTHORS INFO & AFFILIATIONS

Publication: American Society of Clinical Oncology Educational Book

Volume 42

https://doi.org/10.1200/EDBK_349391