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Adding the Patient to Pathways: Theory and Practice

October 15, 2019

On the second day of the Oncology Clinical Pathways Congress (October 12, 2019; Boston, MA), Alan Balch, PhD, CEO, Patient Advocate Foundation, and Mishellene McKinney, RN, MHA, OCN, Roswell Park Comprehensive Cancer Center, spoke in the first part of a two-part session titled “Clinical Pathways Beyond Treatment Decision Support.”

Both of their presentations sought to expand attendees’ thinking about the utility of pathways in enhancing the patient experience—how pathways can support high-quality care through more than just clinical decision support on therapy choices. 

The benefits of pathways in assisting in treatment choices is established and has been the primary focus of pathways historically. The classic aim of pathways is to standardize care and reduce inappropriate variation in care while ensuring all care choices are evidence-based. But Dr Balch said we should also think about pathways as a tool to maximize appropriate variation in care based on each patient’s unique situation.

The clinical research and approval environments are rapidly evolving in response to dramatic advances in precision medicine, and the call for more patient engagement and patient-centric care also is growing. The concepts and goals of standardization and personalization may appear to be at odds with each other, but Dr Balch says he does not think they are mutually exclusive. You can achieve higher quality care while reducing inappropriate variation through either model. Pathways, today, are just currently more focused on standardization and less on personalization, but we can change that.

Increasing the level of personalized care in pathways can be done through the integration of higher quality shared decision-making, more effective care planning, and increased consideration of patient-reported outcomes, he noted. Pathways should not only be informed by clinical guidelines but also fiscal considerations (ie, insurance, travel costs, loss of income costs to patients) and patient-specific goals of care and preferences.

Hardship for cancer patients stems from socioeconomic and environmental factors, not just drug therapy or diagnostic costs, thus pathways should reflect supports and guidance for the other aspects of care to help reduce total care costs and maximize.

Ms McKinney’s presentation went hand in hand with Dr Balch’s session in terms of how to operationalize the need for more personalized care and address patient-specific factors via an effective implementation tool like a pathway. It is not enough to create a pathway and expect changes to happen in care delivery. The implementation of a pathway is just as important as the development of high-quality pathway. Implementation science is the study of methods to improve the uptake, implementation, and translation of research findings into the real world.

Successful implementation is a product of evidence, context, and method. Ms McKinney said, “Research is not just about gaining knowledge; it is about generating change.” Using implementation science, Roswell Park has designed and will soon be launching a patient education pathway; Ms McKinney explained their journey in creating this pathway and their plans for implementation.

They decided to create the pathway after some of their patients had reported they were not adequately prepared to know what to expect during chemotherapy or how to manage side effects when compared to patients at other top cancer centers. The pathway would be a patient education pathway with education interventions built in throughout the care journey at appropriate junctions by various members of the health care team.

She outlined four key steps leading up to the development. First, they performed a “current state assessment.” They objectively assessed how their current processes were performing in practice and looked for gaps in care. They found so much variation in how information was being delivered to patients, when they were getting information, how much was given, and what environmental factors were at play when education was being given. They also engaged all of the key stakeholders and subject matter experts to identify barriers and appropriate facilitators. Then, they reviewed all relevant research related to best practices on patient education and workflow. Next, they brainstormed ideas on what type of intervention would be best in their settings, including areas of focus, specific team members needed, communication plan needs, and to ensure everyone was on the same page. Finally, they developed the implementation plan with key metrics for success and the workflow for the intervention.

Ms McKinney said, “In the end, a pathway is a behavioral intervention; you have to make sure everyone knows what is going on and what they need to do.” Phase 1 of the patient education pathway includes the establishment of clearly defined roles and responsibilities for team members; implementation of the Teach Back Method (ie, asking patients to repeat back what they were just taught); and education checklist; and scheduling of education visits. Phase 2 of the intervention will include enhanced patient financial counseling and prior authorization; a centralized education database; and electronic aggregation and delivery of education materials.

Ms McKinney showed a slide of the pathway itself, which was incorporated into a flow graphic with concise checklists and bulleted lists and included the steps: “Consultation with your oncologist,” Orientation at the resource center,” Your personalized education visit,” and “Active treatment, first day.” The sheet for patients includes the full journey, what to expect at each step, and specifically when certain education will be provided. 

She expressed her excitement prior to going live with Phase 1 of this pathway, which will begin on October 22, 2019. Success will be measured via implementation outcomes (patient/provider reach, feasibility/acceptability, and completion of tasks), service outcomes (clinic wait times, post-education triage call volumes, and admissions for side effects), and patient outcomes (patient-reported confidence of expectations).—Amanda Del Signore

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