A systemwide collaborative integrates palliative care, EHR-based patient flagging, and cross-disciplinary support to address the psychosocial and clinical risks that often derail cancer treatment.
Penn Medicine's Whole Person Care Collaborative is designed to provide comprehensive care for the health system's cancer patients.
Cancer is one of the most challenging serious illnesses that people can face. Cancer patients have a range of needs and challenges beyond treatment of their illness, including psychosocial needs, financial strain, spiritual needs, and end-of-life care.
Penn Medicine has delivered sophisticated cancer therapies for decades, and the health system's Whole Person Cancer Collaborative adds a comprehensive approach to serving cancer patients, according to Ramy Sedhom, MD, medical director of oncology and palliative care at Penn Medicine Princeton Health.
"Sophisticated treatment without the structure to support patients as people who are going through treatment can lead to preventable breakdowns in care," Sedhom says. "You need to have support in place for situations such as emotional crises, unplanned hospitalizations, therapy discontinuation, and struggling caregivers."
An important idea behind the Whole Person Care Collaborative is to provide comprehensive care to cancer patients no matter where they are seen at Penn Medicine, including downtown Philadelphia, Lancaster General Health, and Penn Medicine Princeton Health, Sedhom explains.
"The collaborative is accomplishing this through efforts such as standardizing screening processes, establishing triage pathways, and using the electronic health record to have structured triggers when patients are having distress," Sedhom says.
The Whole Person Care Collaborative has established the infrastructure to provide comprehensive services for cancer patients. Penn Medicine's electronic health record is a foundational piece of this infrastructure. For example, the EHR is being used to flag possible impairments of older adult patients and to generate population health data for a dashboard focused on older adult patients that is valuable for all members of cancer care teams. A social worker embedded in a cancer clinic can review patients who were recently seen and know how many of them have incurable cancers with multi-domain impairments, Sedhom explains.
"For these vulnerable patients, the social worker can see how many have completed an advanced directive," Sedhom says. "This information helps the social worker identify the patients they need to see."
Dedicated staff members who focus on whole person care are another key element of the collaborative's infrastructure.
"We have a staffing infrastructure to help deliver services that impact cancer outcomes," Sedhom says. "This includes teams that are focused on the symptom burden of patients, psychosocial health such as emotional distress and depression, and the financial toxicity associated with cancer care."
Psychosocial therapists in cancer clinics look at patient-reported outcomes related to mental health conditions, Sedhom explains.
"This helps the psychosocial therapists identify the patients they need to see urgently because they have anxiety or depression as it relates to their illness," Sedhom says.
From a healthcare executive leadership standpoint, there has not necessarily been a need to increase staffing to operationalize the collaborative, according to Sedhom.
"Instead, we have restructured or redelegated how we use members of our care teams," Sedhom says. "The whole idea of this collaborative is to make sure every member of the cancer care teams is functioning at the top of their licenses. This is accomplished by redistributing work through defined pathways."
Ramy Sedhom, MD, is medical director of oncology and palliative care at Penn Medicine Princeton Health. Photo courtesy of Penn Medicine.
Importance of Palliative Care
The provision of palliative care services is one of the primary focal points of the Whole Person Care Collaborative.
The collaborative has adopted best practices for palliative care for cancer patients such as moving away from time-based criteria to initiate palliative care services. In the past, if a patient was at risk of death within one year, there would be an effort to get the patient palliative care, Sedhom explains. Now, the organization has shifted to needs-based palliative care.
"The idea is to provide palliative care when certain needs and triggers manifest," Sedhom says. "For example, hospitalizations for patients with incurable cancer can trigger initiation of palliative care."
Another trigger for palliative care is worsening quality of life, Sedhom explains.
"At Penn Medicine, one of the surveys that cancer patients get is called Patient Reported Outcomes," Sedhom says. "This survey features a battery of questions that look at quality of life measures such as nausea, pain, diarrhea, and neuropathy. We follow quality of life measures over time and have built in triggers for palliative care referrals."
Other factors that trigger palliative care services are functional decline and complex-goals-of-care conversations, which according to Sedhom is where palliative care is most helpful.
"Cancer care is best when it is adapted to what is most important to the patient," Sedhom says. "In general, palliative care teams are well positioned to help have conversations about functional decline and complex goals of care."
Christopher Cheney is the CMO editor at HealthLeaders.
KEY TAKEAWAYS
The Whole Person Care Collaborative is designed to provide comprehensive care to cancer patients no matter where they are seen at Penn Medicine.
Penn Medicine's electronic health record is a foundational piece of the collaborative's infrastructure, including flagging possible impairments of older adult cancer patients.
The provision of palliative care services is one of the primary focal points of the collaborative.