Cancer is a complicated disease that takes a significant toll on patients’ physical and psychological well-being, which is why effective treatment encompasses the whole person—body, spirit and mind. Consequently, comprehensive care coordination services are fundamental to any oncology practice.

Care coordination allows the care team to focus on both the mental and physical health of its patients. For example, a nurse on the team may act as a liaison for patients throughout their cancer journey, advising on side effects and symptom management, answering questions, addressing concerns, coordinating community resources and lending an empathetic ear to help support the patient’s emotional needs—and those of caregivers.

A Team Effort

Cancer patients are going through a tumultuous and scary time, which frequently gives rise to questions about treatments and possible side effects. They want questions answered quickly but are often reluctant to call their physician. Frustrations can become exacerbated when patients who do call are forced to leave a message and wait for a return call.

Under care coordination models, patients are assigned to an RN care manager and have access to a nurse 24 hours a day, seven days a week who provides timely answers and advice, calms fears and assuages concerns. These relationships are built on trust and become an important catalyst for preventing unnecessary costs associated with inappropriate trips to the emergency room.

Robust care coordination programs also include dietitians on the patient’s team. Studies have shown that patients who maintain a stable diet while undergoing treatment are more likely to complete the course, which can be lifesaving. Dietitians are able to tailor nutritional plans for patients who, for example, have difficulty swallowing as a result of treatments for head or neck cancer or for pancreatic cancer patients who cannot digest food normally. Patients experiencing weight gain due to treatments can also lean on dietitians for help.

Care Coordination During COVID-19

As coronavirus cases continue to surge across the country, many cancer patients are understandably hesitant to leave the house—especially since they are at a high risk for the most severe aspects of the virus.

At AON, our care coordination team is addressing these very real concerns through telehealth, allowing our dietitians to continue meeting with patients without requiring them to leave their homes. The transition from face-to-face to virtual has gone very well. In fact, more patients are making appointments with dietitians now than they were before the pandemic hit.

The benefit of using telehealth to reach our patients is two-fold. It allows patients to meet with members of their care coordination team from the safety of their own home, and it keeps them connected to people they trust and can rely on during an incredibly stressful and fearful time. The COVID-19 pandemic has been exceptionally difficult for cancer patients, so it is important for them to know that their care is here for them even if we can’t meet physically.

How A Network Can Help

A lot of work is involved in the implementation of a care coordination program and some independent practices may not have the manpower or bandwidth to accomplish it properly.

For practices that partner with AON, a care coordination program is already established for patients who qualify for the Oncology Care Model. Our network’s care management department also offers a variety of support activities, such as refilling medications, meet-and-greet phone calls to new patients to gather information for their clinical team, and managing paperwork. The result is an unprecedented level of care that doesn’t require a practice to add staff or increase costs. With AON alleviating much of the administrative burden, it also allows the practice to focus on its top priority: the patients.

AON also offers an app-based support portal for nurses and dietitians that helps them quickly locate providers of almost any resource they need in their surrounding community. We are currently working on building one that will give patients access to AON’s robust database of resources and community-based services such as housing and assisted living, nutrition, food support, respite care, financial assistance and transportation services.

Treating cancer involves treating the whole patient. A care coordination program enhances a practice’s ability to do so.