Harmesh Naik, MD.

Multi-disciplinary cancer care concepts

Harmesh Naik, MD.

Harmesh Naik, MD.

This is not a sales pitch

Harmesh Naik, MD.

Scope of discussion today

• Limited to discussion of concepts as an educational exercise

• Judge interest level of audience

• First step to understanding the fundamentals of various models

• Understand the benefits of MDC model

• Discussion is not complete because of time constrains

• Interactive

Harmesh Naik, MD.

MDC Concept is not new…..

Harmesh Naik, MD.

Harmesh Naik, MD.

Definition

• No universal definition

• Refers to multi modality care mostly

Harmesh Naik, MD.

Cancer care today

• “complex endeavor”

• “Multi-disciplinary”

• “Multi-modality”

• “involvement of multiple specialists”

• “ referral to many doctors”

• “comprehensive”

• “cutting edge”

• “state of the art”

Harmesh Naik, MD.

Traditional Cancer care

• Requires multiple visits

• Requires multiple physician visits at different locations

• Patient may get variety of opinions

• Requires multiple non-physician support care health staff encounters

• Care is fragmented

• May lead to confusion

Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

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Harmesh Naik, MD.

Patient view

exhausting

confusing

contradictory

distressful

Harmesh Naik, MD.

Patient view

Are my doctors talking to eachother

Who is calling theshots?

Harmesh Naik, MD.

Aliens????

Harmesh Naik, MD.

Alternative care any one?

How aboutcure?

Harmesh Naik, MD.

What does patient want?

All of my doctors working together and ……………….

Harmesh Naik, MD.

What does patient want?

You are fine. It was a baddream……….

All of my doctors working together and ……………….

Harmesh Naik, MD.

TEAM APPROACH

Harmesh Naik, MD.

Multi-disciplinary Clinic (MDC)

• More organized

• Patient friendly

• Easy navigation

• better patient and provider satisfaction

• More uniform management

• Better outcomes

• Comprehensive

• “body, mind and spirit”

Harmesh Naik, MD.

Driving forces

• Comlexity of care

• Patient demand

• Provider demand (newly trained physicians)

Harmesh Naik, MD.

Patient perception

• High quality of care/High level of satisfaction

• Consensus treatment recommendations

• Convenience

• Higher degree of provider involvement

• “Personal touch”

• Less invasive - second opinions

• “one stop shopping”

• “teamwork”

Harmesh Naik, MD.

Time to treatment

0

5

10

15

20

25

30

35

40

45

center non center

days

Gabel et al. Cancer: 79: 2380-2384, 1997.

Harmesh Naik, MD.

Acceptance of MDC

• Patients demand it.

• NCCN:

• “……patient preference is also a major component of decision making process………”

NCCN.ORG, accessed, Sept 16, 2005, Breast cancer guidelines.

Harmesh Naik, MD.

Major organizations

• ACOS approved program

• “a multi-disciplinary team approach to co-ordinate the best cancer treatment options available…”

Commission on cancer: Cancer program standards, 2004.

Harmesh Naik, MD.

More…

• ASCO• “Once a cancer diagnosis is made, it is

important to get the best care possible. Since cancer diagnosis and treatment can be complex, its treatment often involves input from a multidisciplinary team of several types of oncologists; a diagnostic radiologist, a pathologist, an oncology nurse; and support staff such as an oncology social worker, a dietitian, and a chaplain. A team approach combines the skills of several different disciplines into one consulting group”.

PLWC.ORG, Accessed Sept 16, 2005.

Harmesh Naik, MD.

Local preference

• We wanted to find out

• Conducted a non-scientific survey

Harmesh Naik, MD.

Primary care physician survey

• Data as of August 15, 2005

• Total 440 physicians

• 68 (15.45%) returned survey

• 96% responders would like to see integrated cancer care

Harmesh Naik, MD.

Local survey

84

6658

49

40

0

10

20

30

40

50

60

70

80

90

Breast Prostate Lung GI Lymphoma

sites desired

Harmesh Naik, MD.

Referral interest

97

3

0

10

20

30

40

50

60

70

80

90

100

Yes No

Referal

Harmesh Naik, MD.

Interest in participation

• 4-15 physicians indicated interest in participation

Harmesh Naik, MD.

Resources needed (not a complete list)

• Physical space (multiple exam rooms, conference room etc.)

• 800 referral line (a must)

• Clinical co-coordinator

• Clinical nurse specialist

• Dictation system

• Charting system

• Information system

Harmesh Naik, MD.

Resources needed (Ct.)

• Patient forms/consent etc paperwork

• Scheduling mechanism (center, radiology, lab, procedures, consultations, conference)

• Front desk staff

• MDC conference and set up

• Educational resources

• Computer with online access

• Data monitoring/Survey mechanism

Harmesh Naik, MD.

Physician resources

• Interested Participants

• Must define a lead physician “driving force”

• “A team leader”

Harmesh Naik, MD.

Physician team members

• Medical oncologist

• Radiation oncologist

• Surgeon

• Radiologist

• Pathologist

• PCP

• Specialist need based on site (CT surgeon or neurosurgeon, plastic surgeon etc.

Harmesh Naik, MD.

Non physician team members

• Coordinator

• Nurse practitioner

• Genetic risk counselor

• Dietary counselor

• Psycho-social counselor

• Social worker

• Patient advocate

• Community representative

Harmesh Naik, MD.

Non-medical services

• Music therapy

• Alternative –complementary therapy

• Feel good programs

• Massage therapy

• Support groups

• Innovative ways to help patients and families

Harmesh Naik, MD.

Variety of Models” “with walls”

• Ideal setting

• All physicians see the patients in one designated location, preferable in the same time block

• More suitable fro employed model

• Not suitable for many community hospital because of physician non-participation

Harmesh Naik, MD.

“Without walls”

• Virtual

• Not all physicians are on site, however participate in decision making reaching a consensus

• Nurse coordinator navigates the care and appointments with various physicians depending on management needs

Harmesh Naik, MD.

MDC conference

• Key to success of MDC• Representative of major specialist

make a consensus treatment decision for a patient after obtaining variety of opinions and determine overall management plan

• Documentation of plan• Follows major established guidelines

(evidence based )• Limit to 1 hour

Harmesh Naik, MD.

Logistical issues

• “True multi-modality care is rarely possible” under one roof

• Private practitioner participation is hard to arrange

• Details need be worked out

• Payment for certain services may be problematic

Harmesh Naik, MD.

Goals at SMMH

• Improve quality

• Growth of program

Harmesh Naik, MD.

Availabel resources

• Speciality Physicians

• Majority of ancillary services

• Active tumor board

• ACOS approval

• Improving perception

• Many sevices are in same complex

Harmesh Naik, MD.

What more is needed

• Vision

• Integration

• Initiative

• Dedication

• Enthusiasm

• Patience

• Financial resources

Harmesh Naik, MD.

Baby steps

Harmesh Naik, MD.

Education

• Important component of a MDC

• MDC conference facilitate information exchange

Harmesh Naik, MD.

Still not convinced?

Harmesh Naik, MD.

Question:

• What type of care a physicians want their family members to receive after a diagnosis of cancer?

Harmesh Naik, MD.

Personal experience

• For my family:– You know the answer.

• For my patients– Multi-disciplinary care.

– My lung cancer patients: All major services are available in hospital complex (Virtual clinic).

Harmesh Naik, MD.

Reading

• Oncology issues: July/August 2004.

• Oncology issues, May/June 2004

• Oncology, September 2004: 1263-1275, various authors.

• ASCO.ORG

• ACOS.ORG

• Commission on cancer standards book, 2004.

Harmesh Naik, MD.

Next……

• Coordinator’s perspective.

Harmesh Naik, MD.