Improving Care Coordination for Comorbidity and Cancer: A Necessity for Patients With Cancer.

Abstract

Cancer does not occur in isolation of people’s other chronic issues. Fifty-eight percent of patients with cancer have at least one other chronic or comorbid condition1; thus, cancer is only one of the diagnoses and treatments they have to deal with. Although patients with cancer often experience issues with long-term functional, psychological, and physical adverse effects from cancer treatment that negatively affect their quality of life,2,3 it is important to remember that chronic illnesses also add to patients’ cancer-related issues.4,5 In order to ensure quality patient outcomes, care needs to be continuous, consistent, and unique to each patient’s healthcare needs including existing comorbid conditions.6 This means that care coordination between oncologists and primary care providers (PCPs) who manage the existing chronic conditions is essential for comprehensive cancer care. Coordination of care is critical in ensuring that all of the healthcare needs of the patient are met including ensuring that all chronic conditions are under control during cancer treatment.7 Currently, care for patients with cancer is fragmented—siloed with very little interaction between the oncologist and PCP.8–10 The lack of care coordination increases the risk for poor outcomes and limits the patient’s quality of life.1 Lack of care coordination can lead to inadequate care as the care becomes fixated on the cancer while other health issues go unattended.11,12 This lack of coordination can also lead to fragmented care, polypharmacy, adverse drug reactions, toxicity, unplanned hospitalizations, uncontrolled chronic illnesses,13 and higher healthcare costs. With increasing survival rates, new models of care, and longer life, the role of the PCP becomes even more important and should be integrated into the cancer care trajectory from the point of diagnosis forward. Patients trust their PCP, and they can provide valuable support during diagnosis, selecting of treatment options, treatment phase, stability, recurrence, palliative care, and end-of-life care.1 Primary care providers have important roles during these phases such as managing comorbid conditions, managing depression, establishing do-not-resuscitate status, and discussing/referring patients to hospice. Having the PCP involved throughout the entire care trajectory allows them to be involved in care and better understand the patient’s needs.1 About 20% of survivors report they did not see a PCP in the second year following their cancer diagnosis.1 Survivors who report having both an oncologist and PCP involved in their care perceived higher quality of their care.1 Improved outcomes and higher quality of care occur when both PCP and oncology specialist are involved in the care.1 Guidelines need to be developed that consider both the treatment of the comorbidities and the cancer simultaneously. Such guidelines could assist providers (oncologists and PCPs) in understanding when cancer treatment guidelines take precedence over other chronic illnesses and vice versa. Currently, most treatment guidelines exist within the silo of the specialty in which they were developed and thus become problematic when they contradict each other and cause confusion for the patient.14,15 A standard model of care coordination during and after cancer treatment for patients with comorbidities is needed. There is little research on best models of care, or agreement on the roles of each type of provider. What is the best model for comanaging the patient with cancer and a preexisting comorbidity? Is formalized care coordination cost-effective? Does coordinated care result in improved patient care metrics, such as quality of life, patient satisfaction, and outcomes?4 Solutions need to be developed that address the existing challenges and barriers and prevent us from coordination of care at the provider level. Barriers include knowledge and skills (patients and providers), communication (between providers and between patients and providers), and financial cost/resources.16 In order to address each of the barriers and ensure continuity of care, many research questions need to be asked and answered. These include the following: (1) What is the ideal shared care model between oncology and primary care? What would it look like? (2) How do we ensure communication and coordination between providers about their roles starting at the point of diagnosis? How do we include the PCP as a part of the cancer care team? (3) How best can we utilize the electronic health record for this comprehensive patient care? (4) How can cancer care plans be shared with primary care? (5) How do we provide clarity regarding the role each provider plays to the patients so they understand whom to contact about various issues and so that patients understand their preferences are considered? It is important that nurses take the lead in trying to improve the care coordination between primary care and oncology providers. Only then can we have patient-centered cancer care.