NurseNavigator

OurStart� ACardiologistandanOncologist� Enlistleadershipfromcardiologyandoncology

�  Committeeformedwithkeystakeholders:Cardio-oncologyboard

� Members:keyphysicians,leadership,businessdevelopmentandmarketing

�  Goal:Toinvestigateopportunitiesanddetermineprogramcoursedevelopmentforidentifiedpatientpopulation.

� Approach-NurseNavigator�  Criteria–cardiology/oncology

Approach� Nursenavigatormodelwithinoncologypractice

�  10oncologistpractice–communityhospital�  Identificationofpatients–toolforriskassessment� Cardiacsurveillance–monitoringprocesses� Referralprocess� CardiologyandOncologysupport

ApproachCRS-theiden4fica4ontool

� CRS–tool(Mayoclinic) �  HerrmannJ,LermanA,SandhuNP,VillarragaHR,MulvaghSL,KohliM.Evaluation

andmanagementofpatientswithheartdiseaseandcancer:cardio-oncology.MayoClinProc.2014;89(9):1287–306

� Presentationtooncologyboard�  Scope:allpatientswillbescreened�  Initiationoftool:admissionprocess� NewEMR�  Interim:navigatorcompleteandfollowidentifiedpatientsthroughkeyprocesses

� Trackingofpatients–spreadsheetfordata

CardiacRiskScore-CRSDrug

�  4–ex;trastuzumab–(herceptin),anthracycline-(doxorubicin)

�  2–ex:docetaxel,pertuzumab

�  1–ex:bevicitzumab–(avastin),dasatinib(Sprycel)

�  0–ex:rituxamab-rituxan

PatientRisk-1pt.each�  Female�  >65�  HTN�  DM�  CHF�  CAD,PVD,CVA�  Radiation�  PrioranthracyclinesMed+pt.risks=total

CardiacSurveillance� Echoes

� Ordering,scheduling,timing,ownership � Quality–StrainwithDefinity�  Educationandtraining�  Patients–portpatients

�  labs�  Troponins,BNP,chemistry,CBC

� Vitalssigns� CardiacMRI,stresstest,Holters� EDandhospitaladmissions

Deploymentofprocesses�  Identificationofpatients–echo/treatmentplans� Startsmall–diseasespecificordrugspecificwithoneortwooncologists

� Troponins-timing,positiveresults� referral–algorithmwithuseofCRStool� Patientpopulation–cancerpatientswithtreatmentregimen–cycles

Keystosuccess�  Goalofoncologist:besttreatmentforpatient–getthemthroughthetreatmentbasedonNCCNguidelines

�  Goalofcardiologist:assisttheoncologistwithCVmanagementsothepatientmaycontinuetherapywithminimalcardiovascularsideeffects

�  Communication,promptfollowup,buildingofrelationships

�  Echoprocesscompletelyreleasetonavigator�  Engagementbyalloncologist�  Referralprocess–gamechanger

Learning� WAYBIGGERTHANEVERATTICIPATED–startsmall�  Availabilityofcardiologist,availabilityofservices�  Itsaboutthetimingofcaredeliveryfortreatmentplans–appointment/test–expectations1week

�  SteeringCommitteeofworkingparticipantsforongoingevaluationandprogrambuild

�  Clinicalteam–cardiologists,navigator,echotechs,schedulersetc.

�  Contactedkeyprovidersinfieldtobestpracticeandfuturedevelopment

Coding�  ListasmanyICD10codespervisitthatarewarranted,allcancerdiagnoses�  Billingcodesaretheonlywaytheinsurerknowsthepatientsco-morbidities�  Somespecificcardiacdiagnosticcodes

Z4889:Encounterforotherspecifiedsurgicalaftercare

Z5111:Encounterforantineoplasticchemotherapy

Z5112:Encounterforantineoplasticimmunotherapy

Z5189:Encounterforotherspecifiedaftercare

Z92.3hxofradiationtherapy

Z91.89Atriskforcardiomyopathy

Z92.21hxofantineoplasticchemotherapy

Oncologistperspec4veaboutcardio-oncology

�  “Theproactiveapproachhelpstoprovidebetterandmoreappropriatetreatmentplansforourpatients.”

�  “Thecollaborativeclinicmakescareforourpatientsapriority”

�  “Theyhavehelpedtomodifytreatmentplanswithcardiovasculardiseasesothatthepatienthasbettertoleranceandtreatmentprogression”

�  “AssistwithvolumecondensingwhichhasmadehugedifferencewithourCHFpatientsmanagement”

Oncologist’scomments�  “Withtheincreasedattentiontoourpatient’scardiacstatuswecanmovethroughourpatient’streatmentplanswithmoreeaseandconfidence.”

�  “Thefollowupisamazingandourpatient’ssatisfactionwiththemiswonderful;theykeepeveryoneconnected.”

�  “Theinitiationoftheprogramwasadesirableneedforourpatientsbuttheimpactandramificationithashadforourpatientsisdefinitelyobviousfrommyownobservationperspective.Iamsurestatisticaldatawouldalsosupportthis.”

�  “Idon’tknowhowwediditwithoutyou.”

Data

NextSteps�  Firmupfoundationprocesses� Clinic� Education

�  Cardio-oncologyCaseconference–quarterly� DevelopmentofIndianapolisCardio-oncologySociety� Dialoguewithothercardio-oncologistsinsurroundingstatestostartpatientdatabase

� Research-Datacollection–whatisittellingus

Resources�  ACC–Cardio-oncologywebpage�  HerrmannJ,LermanA,SandhuNP,VillarragaHR,MulvaghSL,KohliM.

Evaluationandmanagementofpatientswithheartdiseaseandcancer:cardio-oncology.MayoClinProc.2014;89(9):1287–306.

�  AlbertoDolci,MD,1RobertoDominici,MD,1DanielaCardinale,MD,2MariaT.Sandri,MD,3andMauroPanteghini,MD1,4.BiochemicalMarkersforPredictionofChemotherapy-InducedCardiotoxicitySystematicReviewoftheLiteratureandRecommendationsforUse.ClinicalChemistry–biomarkersofcardio-oncologytoxcity.AmJClinPathol2008;130:688-695

�  CardinaleD,SandriMT,ColomboA,ColomboN,BoeriM,LamantiaG,etal.PrognosticvalueoftroponinIincardiacriskstratificationofcancerpatientsundergoinghigh-dosechemotherapy.Circulation.2004;109(22):2749–54.

�  CardinaleD,SandriMT,MartinoniA,TriccaLabTechA,CivelliM,LamantiaG,etal.LeftventriculardysfunctionpredictedbyearlytroponinIreleaseafterhigh-dosechemotherapy.JAmCollCardiol.2000;36(2):517–22.58.CardinaleD,SandriMT,MartinoniA,BorghiniE,CivelliM,LamantiaG,etal.