The Clinical Pathways Forum: What We Do and Who Should Join

Founded in 2016, the Clinical Pathways Forum is a community of pathways professionals now totaling over 12 institutions from across the United States and Canada who are utilizing clinical pathways in their practices and institutions to improve cancer care. Forum leader Mishellene McKinney, MHA, RN, OCN, organizes quarterly conference calls with Forum members to facilitate discussion of shared experiences and lessons learned regarding pathway use as clinical pathways become more prevalent and evolve to meet the needs of value-based health care systems and reimbursement models.

The Clinical Pathways Forum is a community of pathways professionals founded in 2016 by David Hughes, BSN, former associate director of Clinical Pathways and current data scientist at Seattle Cancer Care Alliance (Seattle, WA), and Mishellene McKinney, MHA, RN, OCN, director of Clinical Pathways and Implementation Science at Roswell Park Comprehensive Cancer Center (Buffalo, NY). As of November 2018, the Forum has grown to include over 12 institutions from across the United States and Canada who are using clinical pathways in their practices and institutions to improve cancer care. 

The mission of the group is to facilitate a knowledge exchange for overcoming the challenges of developing, implementing, and measuring clinical pathways in order to demonstrate the value of standardizing clinical care. The main activity of the Forum is to schedule time quarterly for conference calls in order to share experiences and lessons learned using clinical pathways. Forum members also meet annually for an informal dinner while members attend the annual Clinical Pathways Congress (CPC), a meeting designed to address the operational questions raised by care professionals about the design, development, and implementation of clinical pathways. 

In an effort to increase discussion and collaboration between other organizations using clinical pathways, the Forum will now be publishing highlights from each of the Forum conference calls in the Journal of Clinical Pathways (JCP), the official journal of CPC. This piece is the first of these regular summaries. Health care professionals from across the continuum of care are encouraged to join in these collaborative discussions—Forum organizer information is located at the end of this article.

The November 2018 Clinical Pathways Forum Call

The focus of the November 2018 meeting was to discuss key insights from presentations at this year’s Congress to members in the Forum who were unable to attend. Sessions at CPC 2018 in Boston, MA, centered on implementation challenges, the need for developing pathways spanning across the continuum of patient care, the challenge of developing robust analytics and integrated electronic health records, and the future role of pathways in value-based care models. A few members of the Forum volunteered to summarize the following 5 presentations during the November meeting.

The State of Clinical Pathways: Results from the Inaugural Journal of Clinical Pathways Benchmarking Survey. Winston Wong, PharmD and editor-in-chief, JCP, presented the results of the first clinical pathways benchmarking survey conducted by JCP, which was sent to an industry-wide audience of practicing oncology care providers, and also promoted to members of American Society of Clinical Oncology (ASCO), National Comprehensive Cancer network (NCCN), and Community Oncology Alliance (COA). A total of 74 surveys were completed. The following are highlights from Dr.Wong’s presentation:

• Nearly 68% of practices are currently utilizing, or plan to implement, clinical pathways within the next year
• Improving outcomes (45.7% rated “most important”) was the top decision driver in implementing pathways
• The majority of respondents (95%) are using pathways for medical oncology, with treatment guidelines and medical literature forming the evidence basis for these pathways
• 31% of respondents said their organizations use financial incentives for adherence; 45% of pathway systems are integrated with the electronic health record (EHR), with another 40% still using hard copy/paper pathways. Systems integration of pathways was cited as being one of the biggest challenges to organizations. 

Dr Wong reviewed the responses against the ASCO Criteria for High Value Pathways¹ and found that while most organizations felt their pathways were driven by evidence and over 90% of respondents contributed their input into the pathway, pathway integration with the EHR and analytics are still not meeting the needs of key stakeholders.  

The COME HOME Program. Barbara L McAneny, MD, FASCO, MACP, president, American Medical Association and CEO, Innovative Oncology Business Solutions Inc, discussed how first-responder, nurse triage, and diagnostic and therapeutic pathways were critical to the success of the COME HOME community oncology medical home model.² The COME HOME program was built on the key components of a medical home, which include access and communication, electronic access and prescribing, culturally appropriate care, a team-based approach, managed transitions, personalization, self-care teaching, medication management, and evaluation and outcomes data. The interventions that were implemented to support the model included a triage system, same-day appointments, the ability to function as an urgent care center with diagnostics, patient education, doctors on call, and pathway utilization.  

Dr McAneny illustrated the success of the program through a case study of an 86-year-old man with pancreatic cancer who was successfully triaged and asked to come to the clinic to be seen for confusion. Upon arrival to the clinic, he was found to be in septic shock, was given antibiotics, and then transferred for admission to the hospital. Despite the admission to the hospital, the early intervention resulted in a 2-day admission compared with the standard 10 days. If the patient had instead gone to the emergency room, he would have likely waited for hours without receiving treatment for sepsis, for which treatment delays can result in serious and potentially fatal complications

The overall impact of COME HOME showed a 35.9% reduction in the percentage of patients with emergency department visits, a 43.1% drop in percentage of patients with inpatient admissions, and a  $4,784.08 (22.4%) drop in 6-month total cost of care. The average cost per patient was lowered by $612, and significant decreases in costs of care were seen in the last 30 to 180 days of life. Dr. McAneny emphasized that ensuring participating practices have access to timely performance data, leadership support, and staff that are willing to embrace change and technology are critical to the success of a successful oncology medical home implementation.

Provider Resistance to Pathways: Physician Buy-In & Adoption. Michael A Savin, MD, Knight Cancer Institute Oregon Health & Science University (Portland, OR), discussed the physical and cultural barriers in organizations that impact physician engagement with pathways based on his own experiences. There can be a general sense of mistrust surrounding the use of pathways. Dr Savin explained the importance of including physicians in pathway development and clarifying the purpose of the pathways. Physicians need to feel comfortable that the pathways are kept current, are evidence-based, and that they add value beyond guidelines. How the pathways will fit into individual practice’s workflow and how to minimize the administrative burden of pathways are both key considerations that do not have easy answers.   

Provider engagement can be positively impacted by ensuring that pathways are patient-centric and comprehensive and by generating meaningful analytics. Dr Savin also emphasized the importance of preserving provider autonomy and highlighting the value of pathways that have clinical trial integration to help physicians identify appropriate trials at the point of care.  

Real-World Experience of Pathway Implementation and Evaluation. Roswell Park Comprehensive Cancer Center has had a clinical pathways program in place since 2015. Roswell Park surgical oncologist Stephen Edge, MD, FACS, FASCO, explained how the institute was motivated by several compelling reasons to implement pathways, including better quality of care, patient education, clinical trials at the point of care, continuity of care across the Roswell Park community network, and support for value-based programs with payers. The program began as a collaboration with Moffitt Cancer Center, where the Moffitt methodology was instrumental in facilitating the rapid creation of high-quality pathways. The pathways were comprehensive and multidisciplinary, developed by surgical, radiation, and medical oncologists, and were accessible within the EHR as a reference tool. The Moffitt collaboration was instrumental in engaging clinical staff in the development of pathways. As the program grew, maintaining current evidence-based content, clinical trial notifications, and supporting analytics became difficult to sustain and the search process for a vendor-based solution was initiated. After an extensive search and evaluation process, the organization chose Via Oncology’s Via Pathways.  

Key challenges in the implementation of a point-of-care solution at Roswell Park were proving the value to providers, facilitating EHR documentation, and adding available clinical trials at the point of care. It was important to clearly communicate to providers that going off pathway was not seen as aberrant behavior but expected and critical to the success of the program. Emphasis was placed on the documentation of off-pathway reasons and optimal pathway utilization. In a review of the first 5 months of the program, Dr Edge reported that use across service lines varied but has steadily increased over time with leadership support. 

Dr Edge also noted that Roswell Park has expanded clinical pathways beyond medical oncology and is using pathways as a key element of patient education. In addition, the pathways program has developed comprehensive analytics that are being used to inform value-based care and quality initiatives at the institute.  

Patient Navigation Along a Clinical Pathway: Supporting Multidisciplinary Care Coordination to Improve Clinical Outcomes. Deborah Christensen, RN, BSN, MSN, APRN, discussed how the use of nurse navigators helps to address systems barriers to care. Nurse navigation differs from care coordination in that the latter is episodic, focused more on case management, and has less patient interaction. Nurse navigators help to identify barriers to care such as access to services, transportation, and finance along the continuum of care. Patient interactions are primarily face-to-face.  

The key navigation touchpoints within the pathway begin with a suspicious finding, then move to diagnosis, treatment, survivorship, and end of life. Ms Christensen used a case study of a 31-year-old man who was newly diagnosed with cancer. The nurse navigator contacted the patient prior to the first visit and, upon completion of a barrier assessment, identified that the patient had to travel over 20 miles to the cancer center, had employment and financial concerns, and was feeling anxiety about the diagnosis. He was also experiencing pain and could not take nonsteroidal anti-inflammatory drugs prior to the biopsy. The nurse navigator helped to coordinate pain management with the patient’s primary care physician. The nurse navigator assisted in addressing all of these issues that could have easily been overlooked. As a result, chemotherapy was initiated 28 days from the suspicious finding, followed by radiation, and the patient’s disability paperwork was approved within 1 month. The case study demonstrated that more timely care is possible with better coordination of appointments and by addressing patient barriers upfront.

Ms Christensen reviewed outcome measures of the nurse navigation program in general, noting that there was a decrease in number of days from diagnosis to treatment and that the initial consult time was reduced by an average of 20 minutes. This reflected a total cost savings and revenue potential of approximately $480,000 annually. Physician feedback on the program reflected that providers felt they could spend more time on treatment because the patients came to the first appointment with an understanding of their disease and the logistics of treatment with the nurse navigator’s help. 

For more information about the Forum and/or how to become a member, please contact Mishellene McKinney, MHA, RN, OCN, at mishellene.mckinney-bost@roswellpark.org

References

1. Zon RT, Edge SB, Page RD, et al. American Society of Clinical Oncology criteria for high-quality clinical pathways in oncology. J Oncol Pract. 2017;13(3):207-210.

2. Innovative Oncology Business Solutions, Inc. The COME HOME model. comehomeprogram.com website. https://www.comehomeprogram.com/index.php/come-
home-practices/. Accessed November 29, 2018.