Implementation of a shared oncologic intermediate and acute care unit in times of COVID. Has it come to stay?

Abstract

With aging population and improvement of cancer treatments, the growing number of complex cancer survivors’ challenge the delivery of quality and affordable care. Health care systems need innovate to improve care coordination, patients’ outcomes and experiences and to contain costs. The aim of this study was to evaluate the implementation of an oncology care unit shared between an acute and an intermediate care ward. The shared unit was launched as a response to the COVID-19 pandemic situation that overwhelmed hospital resources and put the quality of care for non-COVID pathologies at risk. The unit is formed by a multidisciplinary team, including oncologists, geriatricians, specialized nurses, therapists and social and psychological support. It is located in a ward with dedicated spaces and activities for oncologic patients. Patients are derived from the emergency ward of the acute hospital after triage or a short stay, when they need specialized oncologic care but without need of complex acute procedures. 
 We conducted a pre-post implementation evaluation using mixed-methods. We analyzed system-level longitudinal data from electronic health records before (historical controls) and during implementation. We performed quantitative and qualitative analysis of patients’ surveys, focus groups with professionals, and interviews with patients and caregivers.
 From January 2018 to June 2020 there were a mean of 160 discharges/month from the acute ward. Since the setup of the Unit in July 2020 until April 2022, approximately 45% (1551; 69 discharges/month) of patients were discharged from the subacute ward. Most patients (75.5%) were derived directly from the emergency unit of the acute care hospital or after a 1 day stay or less, thus avoiding acute hospitalization. During the implementation period patients attended in the subacute ward were older (67.9 vs 63.5), had higher comorbidity weight (GMA: 15.2 vs 13.5) and higher complexity (patients with complex chronic conditions due to health or social needs: 9.4 vs 7%; patients with advanced chronic conditions due to limited life expectancy or end of life situation: 20.7 vs 15%). Consequently, the number of complex patients in the acute ward decreased while the total capacity of the system increased.
 The focus group with professionals (n=15) revealed different arquetypes of patients: subacute care, symptoms control, end of life care and social problems; and caregivers: adjusted/unadjusted to the situation. Positive and negative aspects perceived by professionals were contrasted with those of patients. Professionals highlighted multidisciplinary and availability of adequate spaces and activities as positive values, patient valued the professionalism and humane treatment. Some improvement actions are taking place to improve the provision of information to patients.
 In conclusion, the shared intermediate oncology unit increases the total capacity of the oncologic care system and avoids acute hospitalization to complex patients due to age, comorbidity and social needs. Experiences of professionals, patients and caregivers are mostly positive. "