Transforming Cancer Care

Leaders from UNC Health Care are driving outcomes and patient engagement through a multidisciplinary model.

This article appears in the July/August 2014 issue of HealthLeaders magazine.

The National Cancer Institute designates 41 U.S. hospitals as comprehensive cancer centers, with each required to demonstrate excellence in laboratory, clinical, behavioral, and population-based research, and to set high standards for outreach and education. This puts the University of North Carolina Lineberger Comprehensive Cancer Center in the same category as the Mayo Clinic, M.D. Anderson, and other leading cancer centers.

What makes the UNC Lineberger Comprehensive Cancer Center stand out is its mission to provide cancer care across the state, from rural areas to the thriving Raleigh/Durham/Chapel Hill metropolitan area. The flagship N.C. Cancer Hospital treats patients from every county in the state, with more than 135,000 patient visits a year. UNC physicians treat all cancers and participate in more than 225 cancer clinical trials.

Like many health systems looking to grow their footprint following healthcare reform, UNC Health Care has merged with or acquired other hospitals in the state, including High Point Regional Health System in 2013. UNC Health Care has everything from a state-of-the-art academic cancer hospital to a critical access hospital. Cancer care across different UNC Health Care facilities is delivered by a mix of faculty physicians, employed physicians, and independent oncologists. Even with this range of facilities and expertise, the goal is the same, says Ian Buchanan, MD, vice president for cancer and children's services for UNC Health Care.

"We are really spending a lot of time thinking about and planning how to link together our oncology services to provide seamless cancer care for people across the UNC Health Care system," Buchanan says. "Our goal in the next few years is to be able to say with confidence that if somebody goes to one of our affiliated hospitals that's 150 miles from here, they're going to get 'UNC cancer care' even if they're in a different location."

Cancer care, by definition, should be multidisciplinary, as many treatment plans involve more than one specialty, including surgery, radiation oncology, and medical oncology. Beyond physicians, cancer treatment brings in a host of other professionals—nurses, care managers, pharmacists, therapists, nutritionists, and technicians—who all need to communicate and collaborate. Buchanan says even as the health system has expanded its cancer footprint, there has been a lot of focus on reinforcing teamwork.

"One of the things that we've been successful at, particularly in the last couple of years, has been in having less of a culture of 'us and them,' where it's the doctors versus the hospital staff," Buchanan says. "It is really getting to the point where we're all in this together."

A major step that facilitated more team interaction this year was a systemwide implementation of an Epic-based electronic health record, which brought together the cancer center's physicians, nurses, pharmacists, and other team members to work on care pathways and implementation programs.

"One of the unanticipated benefits of our implementation of Epic is that it put all of our clinical folks—nurses, doctors, pharmacists—all into the same boat, and they all had to paddle together to get ready to go live with Epic," Buchanan says. "That exercise has been very positive at building a culture where we are a cancer team and everybody is doing their part for the patient and the organization."

Lisa Carey, MD, physician-in-chief of the N.C. Cancer Hospital, medical director of the UNC Breast Center, and associate director of clinical science for UNC Lineberger Comprehensive Cancer Center, says the cancer program is "a technically and operationally multidisciplinary model." At the flagship N.C. Cancer Hospital, the collaboration is enhanced by proximity, she says.

"We are all in the cancer hospital together," Carey says. "We view our cases together—surgery, radiation, oncology, medical oncology, genetics, pathology, and radiology are all in the same room at the same time for a couple of hours every week. So when we have issues that relate to the best approach for the patient,
we can have those conversations as a group, which facilitates decision-making tremendously."  

Carey says that unlike some programs, where certain days are scheduled as disease-specific clinic days, at UNC "we're there all five days of the week. So even oncologists that have strong research programs also have a strong presence in the clinic. And that's true of the surgeon or the radiologist. So every day is at least theoretically a multidisciplinary care day, and it's not infrequent that I will walk a patient over to the surgeon or he will walk a patient over to me for a consultation."

That multidisciplinary approach extends to cancer physicians outside Chapel Hill, with at least 15 disease-specific tumor boards a week, Buchanan says. Physicians across the state are able to join via videoconference.

"Any doctor in the state who wants to can get a camera from us and join in," Buchanan says. "On one end of the spectrum, if they want to just listen to the discussion, they can do that. And at the other end of the spectrum, if they want to have their patients' pathology and images sent here, we can include their patients on our tumor board list and have our specialists give input on the patient. That gives the patients the opportunity to be treated in their home communities because we have a lot of very good community oncologists in North Carolina."

The collaboration extends to the nursing leadership as well. Meghan McCann, RN, MSN, director of oncology for UNC Hospitals, says it's helpful that the nursing leaders on both the inpatient and outpatient sides report to her.

"I think that gives us an opportunity to ensure continuity of care," McCann says. "Cancer is a chronic illness. Patients have various touch points throughout their care continuum, both inpatient and outpatient. By all working together and being one team of leaders, we ensure that quality of care and that continuity is consistent across office visits, inpatient stays, or outpatient. So, for example, when we take care of a central line, we're doing that the same way whether the patient comes into one of our clinics or whether they are being cared for as an inpatient."

A key member of that team is the nurse navigator, who is the connection point to the clinical team for those patients with more complex cancers, McCann says. "If the patient is identified as complex, it is very possible that they'll have surgery, have a medical oncologist, and have a radiation oncologist. So the navigator is that touch point for them throughout that process."

The nurse navigators specialize in disease groups and are connected to patients as soon as they are brought into the system, McCann says. The navigators usually are with the patient and physicians during the clinic visit to answer any questions and complete patient education. The navigator is also the one who funnels information from the patient to the care team, and serves a triage role in case the patient has further symptoms and needs more help, McCann says.

Overseeing the teamwork is a leadership structure that reinforces communication and accountability. "Our physicians and our nurse leaders have been in consistent communication," McCann says. "We have a weekly leadership meeting that includes physician, nursing, and hospital leadership. We discuss what's going well, what our needs are, how we can improve the operations, meet patient needs, and discuss strategic plans for the service line. It is not always perfect, but open dialogue and formal standing opportunities to have those discussions with our leaders are keys to the success we have had."

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This article appears in the July/August 2014 issue of HealthLeaders magazine.