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Hanna Sanoff, MD, MPH

Medicine’s Value Care Action Group (VCAG) encourages the redesign of patient care that can introduce improvements for high-value outcomes. The newest VCAG project, led by Hanna Sanoff, MD, MPH, focuses on better serving cancer patients who experience symptoms that need to be addressed quickly, but don’t necessarily require a visit to the emergency room.

“Patients with cancer often experience symptoms from their cancer and their cancer treatments, and these symptoms can wax and wane over time,” said Sanoff, associate professor of medicine in the division of oncology. “We see our patients at regular intervals, such as every 4 weeks; however, their symptoms are often worst a few days after receiving treatment during a visit.”

Educational tools help patients manage their symptoms.

Improving the Patient Experience

Sanoff saw the need to improve how the symptoms patients experience with chemotherapy are managed. Part of the solution was establishing easier access to care when they needed it most. The redesign would enable patients to present to the UNC Hospitals Outpatient Infusion Center, rather than having to go to the ED. In the infusion center they could receive evaluation and management of uncontrolled nausea, diarrhea, and pain, and have work up completed for a rash. Prior to COVID, providers were also able to evaluate patients with fever, and rapidly initiate treatment for those with infection while waiting hospital admission.

Darren DeWalt, MD, VCAG Medical Director, explained how the project evolved. “As the team began to design a schedule for seeing patients at the infusion center, they also found that it was important to engage patients in the process, so that they knew to call ahead before heading directly to the ER,” said DeWalt. “If they called ahead, it might be possible to prevent an ER visit.”

With this realization, Sanoff says the team came to discover many opportunities to improve communication with patients, which resulted in months of refining processes, removing redundancies where possible, and working to streamline communication. The result was an expanded focus starting with the phone room, that took process mapping through to the admission process.

“We found that our patients were frequently going to the ED without calling in for advice about symptom management—so if we didn’t know they were struggling we couldn’t bring them in for an acute care visit.”

Providing Patient Education

Right away, the team began creating patient-centered education materials about what symptoms are emergent and do require an ED visit, and what symptoms are ok to call about and receive advice. Materials were created in partnership with patient and family advisory council members, and piloted in Spanish and English, before being rolled out. Patient education materials are now distributed in the clinic, with reminder tools, including fridge magnets and key chains that provide a “stop” sign reminder for patients to check on their education tool to determine if a symptom is one that’s expected and not worrisome (green light), one they should call about (yellow light), or one that providers feel is urgent, indicating they need to go to the ED or call 911 (red light).

“During patient-physician encounters we talk with patients about warning signs to look out for like uncontrolled vomiting, diarrhea, fever and when to call us. But, we are imparting a huge amount of information to them all at once. We realized that our patients would benefit from tools that could help them understand and navigate the symptoms they experience from chemotherapy treatment. Ultimately, our project ended up encompassing a wide variety of activities, including proactive patient outreach for needs assessment, patient education, process refinement, and provider education.”

Sanoff says the project will continue to be a work in progress for many years to come, but she’s confident the team is on the right track.

“We want our patients to get timely care in the place that is the safest for them. We also need to be able to engage our patients not just during their visits, but throughout their daily experience with cancer. This is going to need to be a combination of acute visits, proactive outreach, risk-based navigation, and hopefully in the near future, patient-reported symptom monitoring. There’s much to be done, but the team is committed to improving these processes so that our patients get the best quality care for their cancer.”

Value Care Action Group

This redesign of care for patients receiving cancer treatments is one of many Value-Care Action Group improvement efforts taken up by the UNC Department of Medicine. Ron Falk, MD, chair of the department created the group and appointed champions in each medicine division, encouraging the review of current practices that look for improvements for high-value outcomes in healthcare. High-value is defined by the quality of patient-centered care achieved per unit of cost. Scott Keller is the director of business development keeping the team focused on value-oriented care models. Darren DeWalt, MD, serves as medical director for the team and helps define the projects. John Vargas is the project manager.