Cancer Health Care Disparities: An Integrative Oncology Leadership Collaborative Case Study
Introduction
NCI-Designated Cancer Center Moves Toward Offering Integrative Oncology
The Sidney Kimmel Cancer Center is part of Jefferson Health, a network of 18 hospitals and physician practices throughout the Delaware Valley. The NCI-Designated Cancer Center is certified by the American Society for Clinical Oncology for providing Patient-Centered Cancer Care.
The Supportive Cancer Care Program within the Sidney Kimmel Cancer Center provides cancer patients, many of whom speak Spanish, with relief from symptoms, pain, and stress. Established within the Division of Supportive Oncology in 2021, the Supportive Cancer Care Program provides an overarching structure for supportive cancer care. The program helps staff:
- coordinate available services and programs;
- understand which staff members manage various services and programs;
- understand the referral pathways for helping patients access supportive cancer care; and
- conduct research on supportive cancer care services and programs.
Within the Supportive Cancer Care Program, the Cancer Support and Welcome Center is the hub for providing patients with information and support from the time of diagnosis. All evidence-based programs are free and open to patients and their family members, as well as staff. Programs include:
- support groups
- educational programs
- mind/body programs
- social and peer connections
- community resources
“We are very committed to the holistic care of our patients. This is part of the DNA of our center.”
Administrative Director
Division of Supportive Oncology
Sidney Kimmel Cancer Center at Jefferson Health
Many programs are available both virtually and in person. The programs offered are based on regular surveys of patient needs and desires.
Participation in Cancer Support and Welcome Center Programs
From July 2021 to June 2022, 4,222 people participated in 379 Cancer Support and Welcome Center programs. The most popular programs and the percent of patients and family members who participated were:
- support and networking groups: 23%
- mind-body wellness: 19%
- educational programs: 13.6%
- special events: 9.5%
- other services: 3.1%
Staff accounted for 31.7% of participants in programs.
Programs for Staff
The Cancer Support and Welcome Center began offering more programming to support staff in 2021 to alleviate stress and burnout caused by the COVID-19 pandemic. “We wanted to make sure we were taking care of our staff so they can take care of their patients and families,” says Gregory Garber, MSW, LCSW, Administrative Director of the Division of Supportive Oncology at the Sidney Kimmel Cancer Center at Jefferson Health. Staff programs included:
- Schwartz Center rounds
- mindfulness for professionals
- evidence-based strategies to help cope with anxiety, distress, and loneliness
- technology and practice updates
- group supervision
Schwartz Center rounds, an international program, offers providers a regularly scheduled time to openly and honestly discuss the social and emotional issues they face in caring for patients and families. Mindful Moments included a 5- to 20-minute mindfulness practice. Other programs, such as Coping Effectively Through COVID-19, lasted 20 to 30 minutes. Coping Effectively Through COVID-19, led by a licensed clinical psychologist, offers evidence-based strategies for coping with anxiety, distress, and loneliness.
Results of Staff Support for the Sidney Kimmel Cancer Center
Behavioral Health for the Front Line: Lessons from the COVID-19 Pandemic, published in the New England Journal of Medicine in 2021, summarizes the behavioral health services offered to health care providers, students, faculty, patients, and caregivers during the COVID-19 pandemic, including health care providers in the cancer center.
The Cancer Support and Welcome Center at Sidney Kimmel Cancer Center had programs for its health care providers twice a week to address self-reported loneliness and distress. Ten to 20 participants attended each program.
Coping Effectively Through COVID-19 decreased distress among cancer center staff members from a mean score of 5.51 at the start of the session to 3.03 afterward. Mindful Moments decreased distress from 5.36 to 3.48. 1
Other Cancer Care Support Services and Programs
Outside of the Cancer Support and Welcome Center, other supportive cancer care services and programs at the Sidney Kimmel Cancer Center at Jefferson Health include:
- patient support programs, including a financial advocacy program;
- The Neu Center for Supportive Medicine and Cancer Survivorship and Supportive Cancer Care
Program, which offers holistic psychosocial cancer care, including pain and symptom management and individual and family counseling;
- psychiatric oncology; and
- oncology navigation.
Paying for Cancer Care Support Services and Programs
Most patient education and support programs aren’t billable. The Supportive Cancer Care Program pays for these through philanthropy and institutional support and by participating in demonstration projects such as the Centers for Medicare & Medicaid Services’ Oncology Care Model and Value-Based Bundled Payment Model and the American Society of Clinical Oncology’s Medical Home. Also, the Supportive Cancer Care Program has credentialled all their licensed clinical social workers so that they can bill for individual, couples, and family psychotherapy.
The Oncology Care Model aimed to provide higher quality, more highly coordinated oncology care at the same or lower cost to Medicare. Physician practices agree to payment arrangements that include accountability for finances and performance for episodes of care surrounding the administration of chemotherapy.
The Value-Based Bundled Payment Model is designed to improve quality and reduce costs for inpatient and outpatient care. Participating hospitals and physician practices receive bundled payments for certain episodes of care instead of fee-for-service payments that reward only the volume of care delivered.
The Oncology Medical Home is a system of care delivery based upon coordinated, efficient, accessible, and evidence-based care. It includes a process for measuring outcomes to facilitate continuous quality improvement.
Psychotherapy and Medical Cannabis
Staff also help patients who want to be certified for medical cannabis but can’t afford the process by using palliative care visits and discretionary funds to help pay for their medical cannabis cards. Patients are only responsible for their usual co-pay for the palliative care visit.
Institutional Support
The Supportive Cancer Care Program tracks services and programs to demonstrate the value to hospital administrators. They have shown that supportive cancer care results in fewer visits to the emergency department and fewer hospital admissions.
An Opportunity to Move Toward Implementing Integrative Oncology
The team at the Supportive Cancer Care Program wanted to do more to address health care disparities, including by making integrative medicine more accessible and moving toward offering integrative oncology.
Many cancer patients are interested in integrative medicine, which at Jefferson Health is a separate department outside of the Sidney Kimmel Cancer Center. Integrative medicine services, however, require out-of-pocket costs, which many cancer patients cannot afford. Staff are working with the integrative medicine department to find ways to increase access to integrative medicine visits.
Addressing Disparities in Cancer Care
The Supportive Cancer Care Program focuses on many types of disparities, including finances (such as costs for parking and childcare), health literacy, and digital literacy.
“The diagnosis of cancer shakes people’s worlds and impacts every aspect of life. Patients uniformly feel better when using integrative oncology.”
Professor, Medical Oncology and Integrative Medicine & Nutritional Sciences;
Faculty Fellow, Jefferson Humanities & Health, Sidney Kimmel Medical College; and Director, Integrative Oncology, and Associate Director, Diversity, Equity, and Inclusion, Sidney Kimmel Cancer Center
“Integrative oncology and wellness aren’t new. But they’ve been used mostly by people with the ability to access them. We wanted to take integrative oncology a step beyond that and make it accessible to all cancer patients.”
An Opportunity to Focus on Integrative Oncology Care
Garber led the Sidney Kimmel Cancer Center team in the Integrative Oncology Leadership Collaborative. Team members included other staff from the Supportive Cancer Care Program and Dr. Lopez and other staff from integrative medicine.
The Integrative Oncology Leadership Collaborative gave the Sidney Kimmel Cancer Center team the opportunity to focus on integrative oncology while helping to create, test, and refine the HOPE for Cancer Care tools to make whole person cancer care routine.
HOPE stands for Healing-Oriented Practices & Environments. The HOPE for Cancer Care tools are based on the HOPE Note Toolkit, a set of integrative health tools developed for use in whole person primary care.
The toolkit contains:
- personal health inventory
- HOPE Note
- personalized health plan
- related supporting tools
The Integrative Oncology Leadership Collaborative
The Integrative Oncology Leadership Collaborative created an approach to integrative oncology called whole person cancer care. This approach focuses on what matters most to the patient and integrates each patient’s personal determinants of healing into their cancer care.
Whole Person Cancer Care
Whole person cancer care focuses on “what matters” to the patient and uses conventional treatments, complementary therapies, behavior, lifestyle, and self-care approaches to combat the side effects of cancer care and help restore the quality of life and length of life for patients.
Through the inclusion of evidence-based therapies such as nutrition, movement, meditation, and others, patients activate their individual ability to heal as they go through cancer treatment and into survivorship.
The Sidney Kimmel Cancer Center was one of 15 cancer centers and other organizations that participated in the Integrative Oncology Leadership Collaborative. Samueli Integrative Health Programs ran the collaborative from April 2021 to December 2022 with a grant from the Samueli Foundation.
Learn more about the Integrative Oncology Leadership Collaborative (PDF).
Addressing Health Care Disparities
Increasing Access to Integrative Oncology Through Group Medical Visits, Translation of Patient Resources, and Integrative Medicine
During the Integrative Oncology Leadership Collaborative, the Sidney Kimmel Cancer Center team focused on addressing health care disparities among cancer patients by planning group medical visits, beginning work to offer patient resources in Spanish, and working to make integrative medicine accessible to more cancer patients. The team moved toward offering integrative oncology.
Integrative Oncology Group Medical Visits
After the first year of the Integrative Oncology Leadership Collaborative, the Sidney Kimmel Cancer Center team decided to use what they were learning to develop integrative oncology group medical visits. Group medical visits, also known as shared medical appointments, combine medical care, health education, and peer interaction. They are a way to address health care disparities by increasing patient access to integrative oncology and to generate revenue from integrative oncology services.
“With integrative oncology, we can help people stay as well as possible during the cancer experience.”
“Group visits are in the context of regular life. People learn from each other and share their experiences about what’s working and not working. That’s often more powerful than what I say,” says Dr. Lopez, who has extensive experience in facilitating group visits.
Integrative Oncology Group Medical Visits Increase Access
The Sidney Kimmel Cancer Center team learned about integrative oncology group medical visits when leading integrative oncologist Donald Abrams, MD, gave a presentation to the Integrative Oncology Leadership Collaborative. A Professor Emeritus of Medicine at the University of California San Francisco, Dr. Abrams described the integrative oncology group medical visits he started at the UCSF Helen Diller Family Comprehensive Cancer Center and results of his research on the program.
A study of five groups with 32 patients by Dr. Abrams and his team found that:
- Patients were very satisfied with the program:
- They rated all aspects of the program as >4.0 on a five-point Likert scale.
- Group visits are a financially viable alternative to individual integrative oncology visits:
- Revenue from group visits exceeded the revenue potential of 6 hours of individual visits by an average of 38%. 2
Dr. Abrams and his team concluded that group medical visits “are a feasible and promising model for increasing access” to integrative oncology.
Along with increasing access to integrative oncology, the integrative oncology group medical visits at the Sidney Kimmel Cancer Center will help address health care disparities because they will be free and available in English and Spanish. Group medical visits enable cancer centers to generate revenue from integrative oncology services because proper coding enables providers to bill for individual and group medical visits.
Supportive Medicine Care Visits at the Sidney Kimmel Cancer Center
The group medical visits at the Sidney Kimmel Cancer Center, called Supportive Medicine Care Visits, will be co-led by Dr. Lopez and a social worker. The three-part group medical visits focus on helping people with cancer and their caregivers identify and develop goals related to quality of life. Each session will last two hours and include:
- group discussion and learning
- didactic learning
- individual visit with social worker and physician
Three topics that patients want to learn about will be covered:
- cannabis and supplements
- energy and activity
- relationships and sexual function
Dr. Lopez and the social worker will use the HOPE Note in the group medical visits to focus on what matters most to patients and family members.
The Sidney Kimmel Cancer Center team had planned to launch the group medical visits during the Integrative Oncology Leadership Collaborative. The team decided to postpone the launch until they could allocate sufficient resources, determine how best to engage patients, and work out the details for making the group medical visits part of the delivery and reimbursement systems at Jefferson Health.
The team has continued to work on the supportive medicine care group medical visits and plans to launch them in the summer of 2023. See Next Steps for more information.
In the meantime, Dr. Lopez is facilitating informal group visits for patients who want to learn more about integrative oncology. She teaches participants about integrative oncology, and they share any experiences they’ve had with integrative oncology with other members of the group.
Translation of Patient Resources
Dr. Lopez also wanted to provide some patient resources in Spanish. The team at Samueli Foundation Integrative Health Programs began working with her to translate some of the patient education pocket guides into Spanish.
Pocket guides provide easy-to-read information about topics that are important to people with cancer. Most guides include information about complementary and lifestyle treatments people can use to feel better. Some offer ways to cope with the emotional and practical aspects of having cancer.
Collaboration with Primary Care Providers
The Sidney Kimmel Cancer Center team began doing more outreach to partner with primary care providers to make integrative oncology more accessible to patients. Guidelines from the American Society of Clinical Oncology, National Comprehensive Cancer Network, and Society for Integrative Oncology all include lifestyle and integrative medicine recommendations. Primary care providers are well positioned to assist patients with making lifestyle changes, especially after active cancer treatment ends. Visits are covered by insurance, giving patients increased access to integrative oncology without paying the full cost of integrative medicine visits at Jefferson Health.
“We are working with our colleagues to raise awareness of lifestyle guidelines, which are integrative approaches,” says Dr. Lopez.
The HOPE Note for Cancer Care
While helping to create, test, and refine the HOPE Note for cancer care tools, the Sidney Kimmel Cancer Center team found the concept behind the HOPE Note to be very helpful.
“The concept spoke to many of us. It’s very patient-centered,” says Dr. Lopez. The Sidney Kimmel Cancer Center team hasn’t formally used the HOPE Note in Supportive Cancer Care Program or integrative medicine yet, but they have used the concept.
Dr. Lopez likes the HOPE Note’s focus on what’s important to the patient. She routinely strives to determine this and works with each patient to develop a plan to address what matters most. “It’s very collaborative and very much focused on the patient,” she says.
Key Insights About Supportive Cancer Care and Integrative Oncology
Assess interest before starting an integrative oncology program.
Although patients are very interested in integrative oncology, buy-in from the health care and other professionals who will be working on the program and the administrators who provide financial support is key in developing a successful program. “Part of our success is our buy-in from a big team,” says Garber. Teams should seek buy-in from physicians, nurses, social workers, nutritionists, and others involved in providing the care, as well as administrators who can provide financial support.
Start small and focus on what is most available.
Starting small makes it easier to succeed and creates momentum for developing or enhancing an integrative oncology program. The first step often depends on what is most available to the cancer center. For example, the first step could be developing or expanding educational programs or building on work in a specific area of symptom management.
Make integrative oncology more accessible through virtual programs.
During the COVID-19 pandemic, the Sidney Kimmel Cancer Center began offering many programs virtually. Many programs continue to be virtual or use a hybrid format where patients can attend virtually or in person. “Virtual programs are so much easier for patients,” says Garber.
Ask patients which services and programs they need and want.
The Supportive Cancer Care Program surveys patients about twice a year to assess their needs and interests. “We use the data to drive programming. People attend things because we’re meeting their needs,” says Garber.
Build a value proposition for the integrative oncology program.
Hospital administrators and payors want to see evidence of the impact of supportive cancer care and integrative oncology. By tracking participation in these services and programs at the Sidney Kimmel Cancer Center, staff have evidence of better outcomes for patients who participate.
“If we want to make the case that this is making a meaningful difference in people’s lives, we need data,” says Garber. “We have to put our academic hats on and think about our goals and the metrics we’re measuring.” For example, providing supportive cancer care at the Sidney Kimmel Cancer Center has resulted in fewer visits to the emergency department and fewer hospital admissions. Metrics could also track improvements in quality of life, mood, anxiety, and so forth.
Garber noted that some types of supportive cancer care and integrative oncology services and programs, such as visits to providers, are easy to track through the electronic health record. Other services and programs, such as seeing social workers, oncology navigators, and nutritionists, is more difficult.
Learn about group medical visits from the experts.
Expert guidance on implementing group medical visits, which can be done in many ways, is available. “Look through the literature and connect with someone who has been doing group medical visits,” says Dr. Lopez.
Two resources Dr. Lopez recommends are:
- The Agency for Healthcare Research and Quality’s Implementing Group Visits In Primary Care Practice: Guide
- The Integrated Center for Group Medical Visits
The Healing Works Foundation also offers “Chronic Disease Management with Group Visits: Integrative Primary Care Case Study.” While this focuses on primary care, much of the information is applicable to cancer care.
An integrative approach benefits providers as well as patients.
When providers see the positive impact of supportive cancer care and integrative medicine on patients, they are motivated to also use an integrative approach to their self-care. For example, Dr. Lopez practices the mindful meditation she routinely uses with her patients, medical students, and other providers.
Along with reducing burnout, using an integrative approach to self-care enables providers to share “tips that are the voice of experience and not just hypothetical.” says Dr. Lopez. “I’ve found the work to be transformative personally.”
Challenges and Lessons Learned
The team at the Sidney Kimmel Cancer Center faced the following challenges and learned the following lessons in their work during the Integrative Oncology Leadership Collaborative.
Developing new services and programs requires perseverance.
The Sidney Kimmel Cancer Center team had planned to start the supportive medicine care group visits during the Integrative Oncology Leadership Collaborative but decided to postpone them due to lack of resources and a need to determine how best to engage patients.
By taking the extra time to consider the best way to launch the group medical visits, the team was able to build interest by tying them to a successful program. “This is a great example of perseverance, creativity, and thinking about what care looks like in our institution and how we can adapt to do new things,” says Garber.
Achieving financial sustainability is difficult.
Most patient education and support programs and integrative oncology services aren’t billable. The Sidney Kimmel Cancer Center has found ways to support its services and programs through philanthropy and institutional support, and by participating in demonstration projects. Being able to demonstrate the value of these programs and services to administrators is key in obtaining institutional support.
Integrative medicine can be costly for patients.
Patients at the Sidney Kimmel Cancer Center are often interested in integrative medicine, but this is a separate department within Jefferson Health that is outside the cancer center, and visits are not covered by insurance. Many patients cannot afford to pay out-of-pocket for integrative medicine visits. Staff in the Supportive Cancer Care Program are working with the integrative medicine department to find ways to increase access to integrative medicine visits.
Helping to Make Whole Person Cancer Care Routine
Along with their work to expand supportive cancer care services and make integrative medicine accessible to more cancer patients, the Sidney Kimmel Cancer Center team worked with teams at other cancer centers to:
- review and discuss the current state of the science and gaps and future opportunities in whole person cancer care; and
- create, test, and refine the HOPE for Cancer Care tools.
Benefits of the Integrative Oncology Leadership Collaborative
Learning From Others Helps Team Focus and Operationalize Integrative Oncology
During the Integrative Oncology Leadership Collaborative, the Sidney Kimmel Cancer Center team learned about successes and challenges in integrative oncology from other cancer care teams, increased collaboration within its team, and began to build a system to support integrative oncology within Jefferson Health.
Learning from Other Cancer Care Teams
Learning from teams at other cancer centers helped guide thinking by the Sidney Kimmel Cancer Center team about their programs and the way in which they were evaluating programs. “We’re all at different stages in the process,” added Dr. Lopez. “The Integrative Oncology Leadership Collaborative brought a broader perspective to the table that was very powerful.”
Increasing Collaboration Within the Sidney Kimmel Cancer Center
“The Integrative Oncology Leadership Collaborative got like-minded people together from all over the country to share ideas and talk about approaches they have taken and their successes and challenges. Everyone had something to share, from the smallest centers to the biggest centers.”
Both Garber and Dr. Lopez noted that participating in the Integrative Oncology Leadership Collaborative increased collaboration and strengthened relationships among members of the Sidney Kimmel Cancer Center team. “The Integrative Oncology Leadership Collaborative got people with shared interests together to brainstorm and collaborate and focused our work,” says Garber. “It informed our thinking about how we do a number of things, such as group visits and gathering and documenting data about our programs.”
Operationalizing Integrative Oncology
An effective integrative oncology program requires structure and a system. Participating in the Integrative Oncology Leadership Collaborative enabled the Sidney Kimmel Cancer Center team to begin to build a system for integrative oncology, such as creating forms to support documentation of integrative oncology in Epic. “Operationalizing integrative oncology is a critical piece of being successful,” says. Garber.
Next Steps
Continuing Work in Integrative Oncology
Garber, Dr. Lopez, and other members of the Sidney Kimmel Cancer Center team continued the work they began during the Integrative Oncology Leadership Collaborative, including launching the group medical visits, tracking services and programs to demonstrate their value, and operationalizing integrative oncology.
Supportive Medicine Care Visits
In late 2022, the Supportive Cancer Care Program began offering Life After Treatment, a 6-week workshop designed to help cancer patients make the transition from active treatment to post-treatment care. Social workers, physicians, nutritionists, and fitness experts guide the discussions and provide training in relaxation and stress management and tips for nutritious eating and symptom management.
“This program was wildly successful,” says Garber. The Sidney Kimmel Cancer Center team decided to use Life After Treatment to recruit patients for the Supportive Medicine Care Visits. During the March 27, 2022, session, they recruited patients for the first supportive medicine care group medical visits, scheduled for the summer of 2023. The team will incorporate the HOPE Note into the group medical visits.
More Tracking of the Value of Services and Programs
The Supportive Cancer Care Program continues to track services and programs to demonstrate their value to hospital administrators. Along with tracking emergency department visits and hospital admissions, staff are reviewing their non-billable interventions to try to measure the impact of individual services and programs.
Operationalizing Integrative Oncology
Work to operationalize integrative oncology and build the necessary systems continues. Dr. Lopez is working with administrators to persuade them of the need for integrative oncology and obtain their support. She and other members of the Sidney Kimmel Cancer Center team are staying connected with some of the other cancer care teams that they met during the International Oncology Leadership Conference and continuing to learn from each other.
End Notes
- O’Hayer CV, Nobleza DN, Inch S, et al. Behavioral Health for the Front Line: Lessons from the Covid-19 Pandemic. NEJM Catalyst Innovations in Care Delivery. July 2021; 2(7). DOI:https://doi.org/10.1056/CAT.21.0109. https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0109. Accessed 3/28/22.
- Thompson-Lastad A, Atreya CE, Chao MT, et al. Improving Access to Integrative Oncology Through Group Medical Visits: A Pilot Implementation Project. J Altern Complement Med. 2019;25(7):733–739. https://pubmed.ncbi.nlm.nih.gov/31314561/. Accessed 3/22/22.
Topics: Cancer | Integrative Health