Weakened from radiation treatment for her brain tumor, Shellyn Burgess fell down the stairs, backwards, in the home of her aunt, Mary Davis, where she’s currently living. Davis was frightened but rather than rush Burgess to the ER, she called Tasha McCaskill-Long, MSN, Shellyn’s case manager in Penn’s CLAIM (Comprehensive Longitudinal Advanced Illness Management) program. Because it happened on a weekend, Long arranged for the program’s triage nurse to go to the house and examine Burgess, who, luckily, had suffered no injuries. The triage nurse reported back to the CLAIM team, explaining what had happened and what steps she had taken. Burgess never had to leave her home.
Had this incident happened before CLAIM started, “we would have waited three to four hours in the ER when she wasn’t feeling well, just to be told ‘Everything is fine. Go home.’,” said Davis.
Using home-care services to improve the quality of care while avoiding unnecessary -– and frequently undesired -- visits to the ER is one of CLAIM’s goal. Patients such as Burgess, who have advanced cancer but are still undergoing treatment, are not yet eligible for hospice, explained David Casarett, MD, director of Penn Hospice and Palliative Care, who created the CLAIM program. “Some don’t want to forgo treatment or the doctor can’t give them a prognosis, two criteria for hospice care. But they still need the symptom management that hospice offers.”
A Focus on Symptom Management
During weekly – or sometimes more frequent – home visits, Long assesses Burgess’s condition and acts as a liaison between her and her oncologist, communicating all information. Much of the at-home care focuses on managing nausea, fatigue and pain, all common symptoms for cancer patients, especially when they’re receiving treatment. “You ask her something and she’ll find out exactly what’s going on,” Davis said, noting that “Shellyn is on so many medications and I don’t always understand what does what. Tasha explains everything.”
Long is also accessible to Burgess and her other CLAIM patients in-between visits, for questions or concerns. CLAIM’s main number –- which is answered 24/7 -- occupies a prominent place on Davis’s refrigerator.
Each case manager –- all of whom are nurses -- reviews cases weekly with Meghan Coleman, DNP, AOCNP, the adult oncology nurse practitioner who oversees all CLAIM patients. But Coleman is available at any time if a situation arises that the case manager can’t handle on her own. “Let’s say a patient needs stronger pain medication but I can’t get the oncologist to respond right away,” Long said. “I’ll consult with Meghan and she’ll make recommendations.” As an NP, Coleman can write prescriptions for short-term narcotics to get the patient through a pain crisis and then confer with the oncologist about the plan of care.
The in-home care ranges from routine tasks (like checking vital signs) to more complex needs, such as wound care, blood work or draining fluid from a patient’s lungs or abdomen, services that might normally require a trip to the doctor or hospital. For example, a bed sore that Michael Prewitt (another of Long’s patients) developed might have landed him back in the hospital but she was able to heal it at home. “Tasha’s care is so precise. She knows what to ask and what to examine,” Prewitt said. “She’s been a tremendous help.”
“Home care nurses allow these patients dignity and a voice in their care in an environment that is less stressful,” Coleman said. The case manager can also connect patients with other at-home services, such as physical therapy.
More Than Physical Needs
The case managers form strong relationships with their patients, which often leads to discussions about their care. “Patients sometimes tell the nurse about symptoms that the oncologist may not be aware of. They worry that if they complain of feeling tired or fatigued, the doctor won’t recommend another round of chemotherapy,” Casarett said. “Or they might confide that they don’t want another round of treatment but are reluctant to talk with their oncologist or their family. The nurse will then initiate the discussion.
“A substantial minority of patients has reservations about their aggressive treatment plan. One of our previous studies [funded by the NIH] showed that one in 10 patients with advanced cancer who are getting chemo didn’t want it,” he continued. “By encouraging conversation, the case worker can help physicians and patients come together.” The CLAIM team also includes a social worker and chaplain.
While providing medical care is the focus, CLAIM staff also try to improve a patient’s emotional state. Prewitt, who is a pastor, is suffering physical symptoms from his brain tumor that has left him weak on his right side and unable to write. “We’re looking into Dragon software so he can dictate his sermons and deliver them to his congregation.”
Since starting in November 2012, CLAIM has cared for over 700 patients. The CLAIM staff now provides daily care for about 120 patients. While not eliminating all trips to the ER, the program has, so far, cut hospitalizations by 40 percent, Casarett said.
CLAIM is currently funded by a $4.3 million, three-year grant from the Centers for Medicare and Medicaid Services. “We’re hoping that the CMS and other payers see the value of this model and continue to support it, at Penn and elsewhere,” he said.
Photo caption: Meghan Cole's visit with patient Michael Prewitt includes a laugh as well as more serious discussions.