36 Oncology IssuesNovember/December 2010

The Exempla Saint Joseph HospitalComprehensiveCancerCenter(ESJHCCC)wasofficiallyestablishedonJuly1,2008,whentwosimultaneouseventsoccurred.First,SaintJosephHospitalsignedacontractwitha cancer center management group. Second, Saint JosephHospitalpurchasedaprivatemedicaloncologypracticecon-sistingoffourmedicaloncologiststocomplementitsexistingradiationoncologydepartmentoffiveradiationoncologists.WeestimatethatESJHCCCwillsee1,600newcancerdiag-nosesandgenerateapproximately80,000outpatientappoint-mentsannually.Thefourprimarycancerdiagnosestreatedarebreast,prostate,lung,andcolorectalcancers.

In September 2009 medical oncology, psychosocialoncology, the infusion center, surgical oncology offices,and the breast center moved to a 26,000-square-footinterimbuildingadjacenttotheESJHcampuswhileanewoutpatientcancercenter isbuiltaspartofa largerhospi-talbuildingproject.RadiationoncologyremainedwithinSaintJosephHospital,butisexpectedtobeincludedwithinthenewoutpatientcancercenterwhencompleted.

Theexecutiveteam’svisionwasanoutpatientcancercen-terthatwouldprovidecomprehensivecarethataddressesalloftheneedsofpatientsandtheirfamiliesthroughoutthecan-cercontinuum.Thiscomprehensiveviewnotonlyincludedalloftherelevantmedicaldisciplinesbutalsopsychosocialoncologydisciplines,includingnutrition.Toensurethatalloftheskillsoftheregistereddietitians(RDs)areaccessed,theexecutiveteamchosetoplacenutritionserviceswithinthepurviewofthepsychosocialoncologydepartment.ManyprogramsarestructuredsothatRDsareforcedtofocusonlyontheclinicalaspectsofcareandareunabletoputtheiredu-cational,programdevelopment,andresearchtalentstouse.Forournewcancercenter,wedecidedthatnutritionalser-viceswouldbebestsupportedandfullyutilizedwithinthepsychosocialoncologydepartment.

Developing the Nutrition ProgramOurfirstconsiderationindesigningthenewcancercenter’snutritionprogramwastheneedsofourpatientpopulation:age,socioeconomicstatus,literacy,andethnicity.Weenvi-sionnutritioncaretoincludedirectpatientcareandeduca-tionfromdiagnosisthroughtosurvivorshipandpalliativecare.Ourhopeistointegratenutritionprogrammingandservicesthroughoutthecancercenter.

Asmentionedabove,intermsoforganizationalstruc-ture, thenutritionprogramis locatedwithinthepsycho-social oncology department; however, the standards ofnutritionpracticeandthestandardsofnutritioncarefortheprogramweredecidedbytheregistereddietitian.

The American Dietetic Association (ADA) and theOncologyNutritionDieteticPracticeGroup (ON-DPG)published Standards of Practice (SOP) and Standards of

ProfessionalPerformance(SOPP)in2008.Thesestandardsare forRDs inoncologynutrition toevaluate theirprac-tice,identifyareasforprofessionaldevelopment,anddem-onstratecompetency in this specialtyarea.TheSOPandSOPP standardize the quality of oncology nutrition ser-vicesandcanbeusedasabasisforjobdescriptionsandpro-fessionalcompetencies.Ourcancerprogramfullyendorsesthefollowingstatement:

“RDs working in all cancer-related practice settings need to develop the appropriate skills, competencies, and knowledge to provide safe and effective care across the cancer continuum…to meet the growing demand for nutrition and lifestyle interventions for individuals affected by cancer.”1

Building a Nutrition Programwithin a New Comprehensive Cancer Center

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These standards provide the expectation of continuallearning and specialization to be able to provide high-quality nutrition care to cancer patients. Therefore, wedevelopedthefollowingstandardsforESJHCCC’snutri-tionprogram:■■ Standard 1: Dietitians employed by ESJH CCC

mustbe registeredby theCommissiononDieteticRegistrationwithatleastthreeyearsofrelatedexpe-rience.

■■ Standard 2:DietitianswillbecomeaCSOwithintwoyearsofhire.

■■ Standard 3:DietitianswillparticipateintheON-DPGandwillpursuelearningandleadershipopportunitiesincancer-relatedorganizations.

With the standards of practice in place, we next neededto define the nutritional standards of care. The Associa-tion of Community Cancer Centers (ACCC) establishedguidelines with supporting rationale and characteristicsfornutritionalsupportservicesincancercenters,referenc-inginformationfromtheNationalComprehensiveCancerNetwork(NCCN)andtheADA.Theseguidelines,alongwithgeneraldesiredstandardsfrompastclinicalexperienceandphilosophy,guidedthecreationofthefollowingnutri-tionalstandardsofcare:2

1. Registereddietitiansareavailabletoprovideevidence-basednutritioncareandservicestopatientsandtheirfamilies.

2. Registereddietitianswillprovidenutritioncare,basedontheADANutritionCareProcess,topatientsidenti-fiedatriskforhavingnutritionalproblemsorspecialneeds.

3. Registereddietitianswilloperateasamemberof themultidisciplinaryteamprovidingoncologycare.

4. Registered dietitians recognize and respect patientautonomyincancercareand,alongwiththeinterdis-ciplinary team, will manage nutrition and hydrationuniquetoeachindividual.

5. Registereddietitiansprovidenutritionservicestothecommunity, including outreach programs addressingdietaryguidelinesthatreducecancerrisk.

Bottomline:ournutritionprogramisbasedonsoundprin-ciplesthatincorporateevidence-basedpracticestandards.

Establishing Outcomes StandardsDetermining desired outcomes—which can be clinical,practice,orprogramfocused—canbeadifficult task.Weestablishedthefollowingoutcomestandardswithaninitialfocusonpracticeandprograms.■■ Standard 1:Allnewpatientswillbescreenedfornutrition

riskattheirfirstappointmentwithinthecancercenter.■■ Standard 2:Patientsrequestingnutritioninformation

willbecontactedbythedietitianwithintwodays.■■ Standard 3:Nutritionclasseswillbeofferedtoallcan-

cerpatientsandtheircaregiversandfamiliesatleastsixtimesperyearwith90percentsatisfactionincontentandpresentation.

Oncetheelectronicmedicalrecordiswellestablished,wewillbeabletosetandmeasurequalitycareindicatorsusingADA’sStandardizedLanguage toachievedesiredclinicaloutcomesaswell.

Cost of Services: Billing and ReimbursementBeforeoutliningthestructureoftheclinicalprocess,wefirst had to determine if the program would charge for

Building a Nutrition Programwithin a New Comprehensive Cancer Center by Shari Oakland, RD, and Jeff Kendall, PsyD

38 Oncology IssuesNovember/December 2010

medicalnutritiontherapyservices.Itwasdecidedthatallclinicalworkperformedby theprofessionalswithin thepsychosocialoncologydepartmentwouldbeprovidedatnocosttoourpatients,includingtheservicesofthereg-istereddietitian.Theexecutiveteammadethisdecisiontoensure thatnobarriersstood in thewayofourpatientsreceiving comprehensive care. In addition, our admin-istration determined that providing these services to allpatientsimprovespatientcare,engagement,andsatisfac-tion,whichmay,inturn,helpimprovemedicaltreatmentoutcomes.

Understandably,thequestionof“whoisgoingtopayfor these services?”canbe thedeciding factor foraddinganFTEdietitianinacommunitycancercenter.Still,sys-temscanbeputinplaceformedicalnutritionservicestobeabillableservice.Historically,thereimbursementprocessofpublicandprivatepayershasbeentediousandrequiresplanning.Toanswerthe“whopays?”question,itiscriticaltopartnerwithreimbursementspecialists tofullyunder-standthebillingandcodingprocessandtoassurecompli-ancewith standards andacceptablebillingpractices.Thearticle by Ganzer and Selle, “Improving ReimbursementforOncologyNutritionServices,” (Oncology Issues,Sep-tember/October2006)isahelpfulresourceonhowtostart

thebillingprocess.Successfulreimbursementcomesfromproving outcomes and demonstrating the cost-benefit ofoncologynutritionservices.3Otheroptionstofinanciallysupporttheroleofadietitianinacommunitycancercenterincludegrant andcharity funding.While these resourcesmaynotalwaysbereliable,theymighthelpsustainanutri-tionprogramwhenfundingbecomestight.

Where Does Nutrition Fit in the Clinical Process?Theanswer:theclinicalprocessbeginsatthetimeofdiag-nosis.AtESJHCCC,allnewlydiagnosedpatientsattendthe New Patient Orientation Class. This one-hour class,presentedbymultipledisciplines,isdesignedtoincreasethepatient’sabilitytoworkwiththecancercentertoimprovetreatmentadherence.Duringthisclass,weintroducealltheservicesandstaffavailabletopatients,includingnutritionservices. Each patient receives a copy of the ESJH CCCPatientWorkbook that includesanutritionsection,writ-tenbyaRD,whichprovidesbasicnutrition informationforbeginningtreatment,aswellasthebenefitsofworkingwithadietitian.Thisprocessensuresthatpatientsarewellawareof thesupportnetworkavailablebefore theybegintheircancertreatment.Futureplansincludedevelopmentof

Medical Nutrition Therapy 101

Nutritionplaysamajorroleinmanyaspectsofcancerdevelopmentandtreatment.Inthemid1990s,nutritionaloncologywasinitiallydefinedasthefieldofscienceandmedicinethataddressesthetotalityofinteractionofnutrientsandothernutritionalfactorswithcancer—spanningthespectrumofcarcinogenesisandcancerprevention,adjunctivetherapy,andsupportivenutritionintervention.1

TheAmericanCancerSociety(ACS)statesthatone-thirdofcancerscouldbepreventedfromanimproveddietandincreasedphysicalactivity.2ThispositionissharedbytheUnitedStatesDepartmentofAgricul-ture(USDA),theNationalCancerInstitute(NCI),theAmericanInstituteofCancerResearch(AICR),andtheWorldHealthOrganization(WHO).Eachoftheseorganizationshaspublishedcancerpreventionguide-lines,includingdietandactivityrecommendations.

Malnutritionisseeninapproximately15to20per-centofpeoplediagnosedwithcancer,andupto80to90percentofpatientswithadvanceddisease.Fiftypercentofpatientsreportabnormaleatingwhendiagnosed.Bycancertype,80percentofpatientswithuppergastroin-testinalcancerandpancreaticcancer,and60percentofpatientswithlungcancerhavealreadyexperiencedsig-nificantweightlosswhentheircancerisdetected.3Dur-ingtreatment,apatient’snutritionalstatusisfrequentlycompromisedbytreatment-relatedsideeffects.Malnu-tritionincreasesmorbidityandmortalityanddecreasesqualityoflife.Itincreasestheriskofpostoperativeinfec-tionandbluntsresponsetotreatmenttherapies.Incon-trast,undesirableweightgainisincreasinglyseenaftercancertreatmentforbreastcancer.Inaretrospectivestudy,29percentofbreastcancerpatientsgained5kgor

moreinbodyweightaftertreatment,4asideeffectthatmayincreasetheriskofrecurrence.Someresearchsug-geststhenumberofbreastcancerpatientsexperiencingweightgainisevenhigher,providingfurtheropportunityfornutritionintervention.

Medicalnutritiontherapyisdefinedas“nutritionaldiagnostic,therapy,andcounselingservicesforthepur-poseofdiseasemanagement,whicharefurnishedbyaregistereddietitian.”5Whiletheeffectsofunder-andover-feedingincancertreatment,recovery,andrecurrencereceivesignificantattention,medicalnutritiontherapyisaimedatmanagingsymptoms,preventingweightloss,andmaintainingoptimalnutritionalstatusduringcancertreatment.

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individualizedcancersite-andtreatment-specificnutritionhighlightsasa“quickstart”guide.

We have developed a standardized routine screen-ingandassessmentprocesstoidentifypatientsinneedofnutrition intervention. The nutritional needs of patientsare screened through a patient self-reported psychosocialdistressscreeningprocess.Thedistressscreeningtoolwasadapted fromNCCN’sdistress thermometer.Withdieti-tian input, we added a nutrition section using questionsfrom the PG-SGA tool. This instrument screens for theintensity of psychosocial distress using a visual analoguescale(0-10),aswellasasymptomchecklisttoidentifythesource of the patient’s distress. Every patient who scoresabovea5outof10andindicatesthatthesourceofstressisnutritionalinnatureiscontactedbytheRDwhoperformsanassessmentofthepatient’sneedsandthenprovidesanynecessaryintervention(s).

This tool is administered to all radiation oncologypatients weekly and to chemotherapy, medical oncol-ogy,andsurgicaloncologypatientsattheirfirstvisitandmonthlythereafter.Thescreening instrumentalsoallowspatientstorequestaprofessionalconsultationwithamem-ber of the psychosocial oncology team. Since a patient’scondition and eating behaviors change during treatment,

routine screening allows for assessment throughout thecontinuumofcare.

Interdisciplinaryroundsoccur in the infusioncenterdaily.Theinfusioncenternurses,aphysician,pharmacist,socialworker,financialcounselor,andRDgathertoreviewthescheduleforthedayandaddressanyissuesorconcerns.Thisprocesscoordinatestheteamapproachandfacilitatescommunicationamongthedisciplines.TheRDcanpresentasummaryofnutritionneedsandcaretotheotherteammembersandalertstafftospecificnutritionalneedsoftheday’spatients.Inaddition,thedietitianattendstheweeklytumorboardandbreast-specifictumorboard.Thispracticeprovidesanopportunityforcollaborativecareplanningondifficultcases.

Thecancercenter’sEMRallowsforadditionalscreeningandreferraloptions.Patientscanbescreenedbydiagnosisandtreatmentregimen,allowingforprioritizationofpatientload.Thisfeatureisespeciallyimportantinradiationoncol-ogy.TheEMRincludes anautomatedreferralandschedul-ingprocessdesignedforphysiciansandothermembersofthepatientcareteamtogeneratereferralsand/orappointmentsfornutritionintervention.

Oncepatientsareidentifiedasneedingnutritioninter-vention,acomprehensivenutritionassessmentiscompleted

Inaddition,earlierdetectionandimprovedtreat-mentshavelengthenedthelifespanofcancersurvivors,withmorethan65percentofpatientsnowsurvivingatleastfiveyears.Aspatientsenterperiodsofremission,registereddietitianscanaddressnutritionalstrategiesthatwilldecreasetheriskofrecurrenceandpossibleco-morbidities,suchascardiovasculardiseaseordiabetes.Thesestrategiesareparticularlyimportantinwomenwithbreastcancer,astheWINSandWHELstud-iessuggestpotentialassociationsbetweendietaryfat,weightloss,vegetableintake,andphysicalactivitywithbreastcanceroutcomes.6,7

Eveninpalliativeandhospicecare,nutritionconcernsareaddressedandinterventionscarefullytailoredtomeetthepatient’sandfamily’sgoalsforcare.Empiricalinvestigationshavefocusedontherolenutritionplaysineveryphaseofdiseaseandtreatment.

Asevidencesupportingtheroleofmedicalnutritiontherapyandahealthfuldietduringandaftercancertreatmentbuilds,theneedforregistereddietitians,andinparticularCertifiedSpecialistsinOncology(CSOs)willincrease(seeboxatright).Screeningandassessmentofbothnutritionandeducationneedsismosteffectiveatthetimeofdiagnosis.Addressingpatientneedsatdiag-nosisprovidesopportunitiesfortheregistereddietitianspecializinginoncologytooffersupportandintroducetheimportanceofscience-basednutritioncarethrough-outthecancercontinuum.Butallcommunitycancercentersdonotincorporatenutritionservicesregularlyintotheirpracticemodel.Accordingtoareviewofinformationofthemorethan700cancercentersontheAssociationofCommunityCancerCenters’website,ofthecentersreportingstatistics,8only51percentreportedhavingadedicatedoncologydietitian.

References1NixonDW,theNOATWorkingGroups,NOATBoardofDirectors.SocietyofNutritionalOncologyAdjuvantTherapy(NOAT)StrategicPlan.Cancer Prevention Int.1997;3:31-36.2CancerStatisticsfor2009.Availableat:www.cancer.org.AccessedOctober2009.3BrueraE.ABCofpalliativecare:anorexia,cachexia,andnutrition.Br Med J. 1997;315(7117):1219-1222.4HeidemanWH,RussellNS,GundyC,RookusMA,VoskuilDW.Thefrequency,magnitudeandtimingofpost-diagnosisbodyweightgaininDutchbreastcancersurvivors.Eur J Cancer.2009.Jan;45(1):119-26.5MedicalNutritionTherapy.Availableat:http://nutritioncaremanual.org.AccessedOctober2009.6BlackburnGL,WangKA.Dietaryfatreductionandbreastcanceroutcome:resultsfromthewomen’sinterventionnutritionstudy(WINS).Am J Clin Nutr.2007.Sept;86(3):878-81.7PierceJP,NatarajanL,CaanBJ,etal.Influenceofadietveryhighinvegetables,fruit,andfiberandlowinfatonprognosisfollowingtreatmentforbreastcancer:Thewomen’shealthyeatingandliving(WHEL)randomizedtrial.JAMA.2007;289-298.8AssociationofCommunityCancerCenters.Availableat:www.accc-cancer.org.AccessedApril2010.

What is CSO?

CSO(CertifiedSpecialistinOncologyNutrition)isspecialboardcertificationthroughtheCommis-siononDieteticRegistration(CDR)anddenotesthattheregistereddietitianpossessesspecialknowl-edge,competency,andexperienceinoncologynutrition.EligibilityrequirementsincludecurrentregistereddietitianstatusbyCDRforaminimumoftwoyearsanddocumentationof2,000hoursofpracticeexperienceinoncologywithinthepastfiveyears.Recertificationisrequiredeveryfiveyears.

40 Oncology IssuesNovember/December 2010

using the Nutrition Care Process. This process providesa standardized approach to nutrition care and includesassessment, diagnosis, interventions, monitoring, andevaluation.Nutritionassessmentscanbecompletedatthechair-sideininfusion,overthephone,oronaone-to-oneconsultbasis.Interventionsarealwaysindividualizedandtake into account cultural, socioeconomic, and literacylevels.Patientscontinuetobemonitoredandinterventionsevaluatedatsubsequenttreatmentvisits.

Nutrition interventions provided by a registereddietitiancan improveapatient’squalityof life,aswellasfunctional outcomes such as improved treatment toler-ance,decreasedweightloss,andreducedtreatmentbreaks.Teachingpatientsaboutnutritioncanallowpatientstoplayanactiveroleintheirtreatment.Nutritionteachingcanalsohelp patients, their families, and the care team to under-standhowcancercanchangethewaythebodyprocessesnutritionandhowitcanaffectoutcomes.

Growing Our Nutrition ProgramOncethenutritionprogramcomponentsweredesigned,weturnedourattentiontodevelopingprogrammingandmar-ketingtoolstohelp“spreadtheword”aboutournutritionservices.Herearethetoolsthatweimplementedtohelpinthiseffort.

Nutrition classes and programs. Theseclassesareawayforus toreacha largenumberof individuals.Thecurrentnutrition class schedule consists of a monthly one-and-a-halfhourclass.Ourtargetaudienceincludespatients,fam-ily members, staff, and the community. Topics can rangefrom cancer prevention to healthy eating on a budget.HavingtheBreastCenteraspartofourcancerprogramalsocreates additional need for classes on weight managementandbreasthealth.Alloftheclassesareofferedfreeofcharge.

Educational materials and community resources.Fromtheinceptionofourprogram,wemadeitapriority

continued on page 42

Lessons Learned■✔ Identify a nutrition champion in the administrative

team or physician’s group.Thispersoncanassistinobtainingresources,navigatingthesystem,andpro-vidingintroductionstokeyplayers,aswellasprovidesupportforincorporatingnutritionintothestrategicplanningofthecommunitycancercenter.

■✔ Educate physicians, administrators, and staff on the value of nutrition interventions in cancer care, as well as current research.Likeours,manycommunitycan-cercentershaveneverhadanutritionexpertonsite.Thedietitiancanprovidetheresearch-basedinforma-tiontoeducatetheteamonthevaluethatnutritiontherapycanbringtothetreatmentplan.

■✔ Have systems in place for policy and procedure devel-opment, as well as standards of care.Itisimportanttoimplementthestructureofthenutritionprograminamannerthatisincompliancewithregulatoryagencies.

■✔ Get to know your client base.Educationlevels,eth-nicbackgrounds,andsocioeconomicstatusarevery

importantpatientvariablesthatchangefromlocationtolocation.Thesevariablesshouldbeconsideredwhendevelopingprogramming,services,andedu-cationalmaterials.Youmustmeettheneedsofyourcommunity.

■✔ Research practice area and available resources.Becomeanexpertandbeknowledgeableanduptodateoncurrentresearch.Connectwithlocalresourcesandnetworkwithotheroncologyprofes-sionalsinthearea.

■✔ Build financial support.Learnhowtofindfunding.Beinvolvedandknowthebudgetprocessforthecancercenter.Researchotherareasoffunding,suchasgrantsanddonations.Askforresourcesandbereadytoshowcostbenefit.Investigatereimbursementopportunitiesanddesignthepracticetobillforservicesshouldtheneedarise.

■✔ Think creatively.Someofthebestprogrammingorservicesarethosethatnoonehasthoughtofbefore.Thinkoutsidethenormofnutritionservicesandbasicassessmentsandinterventions.

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Exempla Saint Joseph Cancer Center At-a-Glance

SaintJosephHospital,thelargestprivateteachinghos-pitalinDenver,islicensedfor565inpatientbedsandisamongthetopthreeColoradohospitalsfornewlydiag-nosedcancercases.InitiatingitsnewcancerprogramonJuly1,2008, ESJHCCCisorganizedacrossthesixclinicalareasoutlinedbelow.

Inpatient OncologyThetwo11–bedinpatientunitsarelocatedwithinSaintJosephHospital.Thetwoinpatientsunitsaredividedintoamedical/radiationoncologyunitandasurgi-caloncologyunit.Socialworkandclinicalnutritionservicesareprovidedbythehospital’scasemanage-mentandclinicaldietitiandepartments,respectively.Thisstructureallowstheoutpatientcancerprogram’ssocialworkeranddietitiantofocussolelyonoutpa-tientappointmentswithinthecancercenter.However,communicationstructuresareinplacesothatpatientinformationflowsseamlesslybetweentheinpatientandoutpatientsettingforcontinuityofcare.Thecancerpro-gram’spsychologistandtheAmericanCancerSocietypatientnavigatorprovideservicesinboththeinpatientunits,aswellastheoutpatientcancercenter.

Radiation OncologyLocatedwithintheSaintJosephHospital,theradiationoncologydepartmenthasapproximately110outpatientvisitsperday.Thepsychosocialoncologydepartmentprovidesallsupportiveservicesforradiationoncologypatients.Atthispointinprogramdevelopmentthehos-pital’sinpatientRDispresentintheradiationoncologydepartmentonedayperweek.Theoutpatientcancercenterdietitianthenseespatientsasneededtheotherfourdaysoftheweekandprovidesanynecessaryinter-ventions.

Medical Oncology and InfusionThecancercenter’smedicaloncologyservicesarecur-rentlyprovidedbyfourmedicaloncologistswithplansofexpandingtoeightoncologists.Theinfusioncenter,nowlocatedintheinterimfacility,hasbeenincreasedfrom12to28infusionchairs.Thepsychosocialoncologydepart-mentprovidesallsupportiveservicesfivedaysaweektothecancercenter’smedicaloncologypatients.

Breast CenterAlthoughthemajorityofpatientsseenattheBreastCenterarenotdiagnosedwithbreastcancer,wehaveincludedtheBreastCenterwithinthecancerprogram.Psychosocialservicesareprovidedtowomenwhoarediagnosedwithbreastcancer.Thebreastsurgeonisanactivechampionforprovidingnutritionservicestoallofourbreastcancerpatientsatdiagnosisandthroughouttreatment.

Surgical OncologyTheclinicalareaofsurgicaloncologyincludesonesurgicaloncologistandtwopart-timegynecologic

oncologysurgeons.Asmentionedabove,inpatientsurgicaloncologypatientsreceivesocialworkandclinicalnutritionservicesprovidedbythehospital’scasemanagementandclinicaldietitiandepartments,respectively.Theprovisionofpsychosocialandclinicalnutritionservicestosurgicaloncologypatientsduringoutpatientinitialandfollow-upappointmentsisstillinthedevelopmentstage.

Psychosocial OncologyThepsychosocialoncologydepartmentisheadedbyadirectorwhoisresponsibleforthefollowingcompo-nents:■■ Psychology■■ Socialwork■■ Clinicalnutritionservices■■ Volunteerprogram■■ Staffwellnessprogram■■ Integrative therapies (i.e., massage, music, and art

therapy,etc.)■■ Graduatestudenttraining■■ ACSpatientnavigator■■ Psychosocialresearch.

Thescopeofallprofessionalswithinthedepartmentfallsintofourdistinctdomains:clinical,programdevel-opment,education,andresearch.Theprimarydomainencompassesclinicalservicesprovidedtopatientsdiag-nosedwithcancer.However,thedepartment’sclinicalinterventions,aimedatsupportingtheneedsofthepatient,arealsomadeavailabletocaregivers,extendedfamily,andanypersoninthepatient’ssocialnetwork.Currently,theclinicalinterventionsaredeliveredthroughindividualoutpatientappointments,telephonecounseling,groupinterventions,andeducationalsemi-nars,andwilleventuallyincludeInternet-basedinter-ventions.

Theseconddomainisprogramdevelopment.Weareinthedevelopmentstagesofimportantpatientprogramssuchas:supportgroups,cancersurvivorshipprogram-ming,educationalseminars,andanewpatientorien-tationclassforbothmedicaloncologyandradiationoncology.Thedietitianplaysaveryimportantroleinalloftheseinitiatives,workingbothindependentlyandcol-laborativelywithotherdisciplines.

Theeducationdomainisbroadlydefinedtoincludebothacademiceducationresponsibilities,e.g.,graduatestudent/medicalresidenteducation,andgeneraleduca-tionresponsibilities,suchasincreasingpublicandstaffknowledgeaboutpsychosocialoncologyissues.Again,oncologynutritionisaprimarytopicinalleducationalarenas,andwearefindingthatrequestsforoncologynutritioneducationarehigherthananyotherareaofthedepartment.Theregistereddietitianisresponsibleforallnutritionaleducationcontentforalleducationprogram-ming—acrossallformats.

Thepsychosocialoncologydepartmentparticipatesinsupportivecareclinicaltrialsincollaborationwithresearchersfromaroundthecountry.Here,too,wearefindingthatinterestlevelsarehighestforclinicaltrialsthatinvolvedietandexerciseassistance.

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todevelopuniformeducationalmaterials thataddressthedifferentissuesthatcancerpatientsface. The “Management of Nutrition ImpactSymptoms in Cancer and Educational Handouts,”which is available fromtheADA,wasahelpful resourcetogetstartedwithoutcomes-basededucationmaterials.Weestablishedatemplatefornutritionhandoutsthatincludedthecancercenterlogoandcontactinformation.Thistem-plateallowedustodevelopmaterialswithaconsistentlookandstructure,asthematerialswereneeded.

Resource kitchen. Ournewcancercenter includesakitcheninthepsychosocialoncologydepartment.Intheplanningphasesforthespace,wedecidedthatthekitchenwould be an ideal location for teaching patients aboutnutrition.Wearecurrently in thedevelopmentphaseofpurchasing equipment for cooking demonstrations. Wearealsostockingthekitchenwithnutritioninformation,including handouts, as well as food containers to teachpatientswhattolookforinalabelwhenpurchasingcan-cerfightingfoods.

Online presence. TheInternethasbecomearesearchtoolthatallowspatientstofindinformationtoguidethemintheircaredecisions.ESJH’swebsitereceiveshundredsofhits eachdayaspeoplenavigate through localhealthcaresystems.Ourteamunderstandsthatitisimportantthatwehaveastrongpresenceonthecancercenter’swebsite(www.saintjosephcancercenter.org).Thisyear todate, thecancercenter’swebsitehashad4,600hitswith1,135to thepsy-chosocialpageand434—nearly10percentofvisits—tothenutritionpage.Wewantedtoensurethatpatientscouldfindthe nutrition information easily and that patients wouldfindtheinformationuseful.Thenutritionsectionisclearlyidentifiedand,inthefuture,willincludehelpfullinksandnutritiontipstodownload.

Integrative medicine. Acombinationofconventionalandcomplementary andalternativemedicine treatmentsshowing evidence of safety and effectiveness, integra-tive medicine has increased in popularity. According totheNationalCenterforComplementaryandAlternativeMedicine (NCCAM), 38 percent of U.S. adults aged 18yearsandoverusesomeformofcomplementaryandalter-native medicine.4 Our Psychosocial Oncology Depart-mentassistsindirectingtheintegrativetherapiesthatareoffered in the cancer center. For example, the dietitianparticipatesinprogramdevelopment,aswellasaddressingindividualquestions frompatients.Thiscollaboration isespeciallyusefulinhelpingpatientsidentifytheappropri-atenessofvitamin,mineral,andherbalsupplementation,aswellastoidentifyscamsversushelpfulproducts.Physi-ciansusethisserviceaswell,askingtheRDsforassistanceinidentifyingproductsthatpatientsbringintotheclinic.

Marketing. Our team had to think about different

ways we could reach our patients andthecommunitytoprovidethenutritionservices we offer. Marketing the dieti-

tian’sservicesrequiredbothinternal (staff,physician, and residents) and external (patients

and individuals within the community) outreach. AsESJH CCC has established community outreach goals,suchas educating thecommunityoncancerprevention,particularly in the prevention of breast cancer, we hadsomeexperienceinthisarea.

Community relations. Newsletters and newspaperarticles provide information to the community and helptomarket thebenefitsofgoodnutrition.Withinthefirstmonth of the cancer center’s opening, a local newspaperpublishedarticleswrittenbytheRDonthetopicofnutri-tionandcancer,highlighting the servicesof anoncologydietitianatESJHCCC.Ourpresenceatcommunityandbusinesshealthfairscontinuestomarketourservicesandpromotenutritiouseatingforcancerprevention.

Future DirectionsCreatinganutritionprogramwithinadevelopingcompre-hensivecancercenterisanongoingproject.Withthesup-portoftheexecutivecommittee,ESJHCCCcontinuestoworktowardsmeetingdesiredoutcomes.Wehavelearnedfromthisprocess (see“LessonsLearnedonpage40)andcontinuetoadjustourmethodsaccordinglytobettermeetpatients’ needs. Changes in our process flows due to anEMR,locationchange,andagrowingpracticechallengeustothinkofnewwaystomeetourpatients’needs.

Ourfuturegoalsaretodevelopprogramsintheareaofresearchandopportunitiesforinternrotationsandsurvi-vorshipprograms.Asourcommunitycancercentergrows,sodotheopportunitiesforthenutritionprogram.Wewillcontinue to educate and provide support to improve thelivesofthoselivingwithcancer.

Shari Oakland, RD, is oncology dietitian, and Jeff Kendall, PsyD, is director of Psychosocial Oncology at Exempla Saint Joseph Hospital Comprehensive Cancer Center in Denver, Colo.

References1RobienK,LevinR,PritchettE,OttoM.AmericanDieteticAssociation:Standards of Practice and Standards of Professional Performancefor Registered Dietitians (Generalist, Specialty, and Advanced) inOncologyNutritionCare.J Am Diet Assoc.2006;106(4):946-951.2Association of Community Cancer Centers. Cancer ProgramGuidelines. 2009. Available at: www.accc-cancer.org/publications. AccessedApril2009.3GanzerH,SelleC.Improvingreimbursementforoncologynutritionservices.Oncology Issues.2006.September/October:34-37.4StatisticsofCAMuseintheUnitedStates.Availableat:http://nccam.nih.gov/news/camstats/2007.AccessedOctober2009.

Our presence at community and business health fairs continues to market our services and promote nutritious eating for cancer prevention.

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