Monday 3rd December 2012
Part three of Sharing good practice, by Louise Smith, Cancer Information Specialist and Centre Manager and Ipswich Project Lead for Survivorship.
The breast and prostate cancer teams at Ipswich Hospital have been testing and implementing new approaches to cancer care for the past two years as part of the NCSI pilot programme.
At the beginning of the programme, the hospital developed a steering group, led by the head matron and including members of the MDT. The group produced a Trust guideline to advise staff on how and when to complete an HNA.
A number of HNA tools are available, but we chose the Distress Thermometer (DT). Our radiotherapy department had previously piloted the tool with 30 patients to help identify their information and support needs. (See Mac Voice, summer 2010).
People said they liked it and that it was quick and easy to use. It helped patients to focus on their issues and concerns, and it helped healthcare professionals make the interactions more focused and efficient. In late 2011, we adapted the tool to include two thermometers - one to measure needs and the other levels of distress.
This approach to needs assessment provided timely and appropriate referrals to other support services, such as the benefits advice, counselling and incontinence and psychosexual support. Issues and concerns that may not have been raised as part of the traditional follow-up process, could be acknowledged and explored, with appropriate information, support and advice offered in a timely manner.
One of the challenges the teams faced was when to offer the assessment. Not all key workers saw their patients face-to-face at every appointment. Time constraints in busy clinics meant they might not have time to sit and go through the assessment with the patient.
Different approaches were tested:
In the radiotherapy department, patients attend on a daily basis so they could either complete the forms while waiting or bring them back the next day.
The urology clinical nurse specialist posted her forms to patients following diagnosis with an explanatory letter and self-addressed envelope. Any concerns were followed up over the phone or at the next appointment.
The breast care nurses gave their forms out at the first appointment following diagnosis and asked patients to return them at their next appointment (around two weeks later) where they would review any issues or concerns with them.
We found patients had more needs and higher distress levels as they moved further along the treatment pathway. The majority of needs were identified at the end of treatment.
Developing a care plan
With the HNA tool in place, we created computerised care plan templates, which reflected the individual treatment pathways these patient groups might follow.
We decided to combine our care plan with the Treatment Summary documentation. The care plan is commenced following diagnosis and the summary completed once primary treatment is finished.
The care plan included:
- results of the HNA form
- information prescriptions or other information given
- signposting and any referrals made to other services.
- the treatment plan
- possible side effects
- key contacts.
Completion of the care plan and Treatment Summary at the end of treatment would either be by the patient’s key worker or following attendance at our ‘Moving on’ education programme, which is led by the survivorship project manager.
A copy of the care plan and Treatment Summary is given to the patient, and another sent to their GP with a request that they review the care plan in 6-8 weeks time.
Finding time to complete the care plan with patients was an issue for all our key workers. When they first started using the documentation, the care plan took on average 40 minutes to complete. With experience this time was reduced to 30 minutes.
The breast care nurses found they needed a laptop to use in MDT meetings so that they could input key data into the care plan to save time. The other MDTs are now adopting this approach.
Where the patient case load far exceeded the number of CNSs or key workers able to support them effectively, we have prioritised patients according to the HNA results. For example, the radiotherapy department refers people with higher needs and levels of distress to a specialist radiographer, while less senior staff look after those with fewer needs, such as referal to benefits advice and other services.
Over the last two years we have piloted the care plan, Treatment Summary and HNA with 220 patients and carers. We sent a feedback questionnaire and self-addressed envelope to all patients and GPs with their copy of the care plan and Treatment Summary. We have received positive feedback from both patients and GPs telling us how useful they have found this approach. Patients say they feel much more confident to manage their symptoms and to think positively about the future following their care planning appointment.
Integrating the system
We now have a CQUIN (Commissioning for Quality and Innovation) payment framework for HNA, care plans and Treatment Summaries in place; a financial incentive, which if we reach our targets, can be reinvested to further improve our cancer services. We are in the process of embedding the care plan into our Trust’s IT system so that it is available to all members of the MDT. Care plan templates have been developed for many different tumour groups and we hope that in time, all people with cancer will be offered HNAs and care plans to support their individual needs, issues and concerns.
The pilot has enabled us to raise the profile of these valuable measures and also gain the support of cancer managers and commissioners to support their implementation.
From Louise Smith and Dr. Alaistair Smith.
- Create a steering group that includes patient, primary care and commissioner representation.
- Make sure you have operational and lead nursing support so that HNA and care plans are embedded into departmental practice.
- Make sure HNA and care planning is an integral part of CNS or key worker work plans.
- Book patients into CNS/key worker clinic slots to carry out the HNA and care plan. This helps to reduce unplanned readmissions and key worker enquiries.
- HNAs are rarely filled in and returned if left in a box in reception for patients to help themselves to.
- Patients and carers are more likely to complete the forms if they know why you are carrying out the assessment.
- Ensure that there is comparison with the social history taken prior to treatment with where the patient is at the end of treatment.
- Volunteers can be extremely valuable in promoting these services, providing administrative support and data input when resources are stretched.
- Consider support from local/national charities in getting these services embedded.
- Establish two or three simple, rapidly auditable standards for the HNA and make sure these can be easily captured in data collection.
- Visit other units with experience and resources to share.
About the author
Louise is the Cancer Information Specialist and Centre Manager at the John Le Vay Cancer Information Centre at Ipswich Hospital. She is the hospital’s project lead for survivorship. Email Louise Smith.
Continue reading Sharing good practice
Back to part one - Holistic needs assessment and care planning
Back to part two - Secondary care perspective
Part four - Evidence base
Anne Wilkinson, National Improvement Lead, NHS Improvement
Part five - Policy
Relevant policy documents.
Part six - Resources
Part seven - References
References for this Sharing good practice.