Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort

Abstract

PURPOSE: Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting. METHODS: We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC. RESULTS: Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic. CONCLUSION: Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer.

Nurse-Led, Telephone-Based Primary Palliative Care Intervention for Patients With Lung Cancer

“…These activities, albeit important, could be delegated to other team members freeing the study nurses to focus on issues that require skilled nursing, such as nonpharmacologic symptom or stress management. 32 The study findings align with several other studies supporting nurses' impact on delivering specific domains of primary palliative care. Houben and colleagues 15 tested the effect of a 1.5-hour nurse-led ACP intervention among patients with chronic obstructive pulmonary disease on quality of patient-clinician communication, prevalence of ACP discussions 6 months post intervention, and anxiety and depression in patients and their loved ones.…”

“…Although the nurses had access to social workers, they felt compelled to help patients in the moment. These activities, albeit important, could be delegated to other team members freeing the study nurses to focus on issues that require skilled nursing, such as nonpharmacologic symptom or stress management 32 …”

Improving Access to Early Palliative Care Delivery for Patients With an Advanced Thoracic Malignancy Through an Embedded Oncopalliative Clinic Model

“…Embedded PC clinic models aim to improve PC delivery by decreasing patient appointment burden, 16 facilitating earlier palliative referrals, 11 and shortening the lag time between PC referral and first palliative clinic appointment. 17 Building on prior studies that have shown the positive effects of embedded clinics on PC delivery, [10][11][12]17 this study further characterizes the changes in referral patterns and palliative referral completion when implementing an embedded PC clinic model among patients with advanced thoracic malignancies.…”

“…Prior studies have demonstrated the feasibility of embedded palliative clinic models in both academic and private practice oncology clinics. [10][11][12] The availability of specialty-trained PC clinicians remains the rate-limiting step for palliative clinic development, while understanding the effect of expanded outpatient palliative resources on patient access and referral patterns is an area of future research.…”

“…Embedded outpatient palliative clinics share space and clinical staff with their oncology colleagues. 8,9 Although pilot studies of embedded PC models have shown improvement in clinical care delivery, including increased PC referral volume and increased satisfaction of both patients and referring physicians, [10][11][12] none have described changes in referral catchment area when transitioning from a freestanding to embedded care delivery model.…”