Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale New Haven.  If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1888-234-4YCC.  This week, Dr. Chagpar welcomes Sandy Hurd and Sherri Storms.  Both are nurse coordinators for the Breast Center at Smilow Cancer Hospital at Yale- New Haven.  Here is Anees Chagpar.
Chagpar        Sandy, maybe you could start off by telling us what exactly a nurse coordinator is?
Hurd             A nurse coordinator is a registered nurse who follows a patient.  We call them to welcome them to the breast center and try to ensure that they bring with them all the necessary information for the physician in order to give them information and education about what next steps they can take and we follow them throughout their care.
Chagpar        Sherri, tell us a little bit about that first encounter.  How important is it that people bring that information with them? Because certainly it sounds like that is one of the key elements that you do.
Storms          We want to make sure that the patients bring all of their imaging, pathology, and their past medical records to their visits so that they can have a quality visit with their physician.
Chagpar        Sandy, you mentioned that you actually call patients.  I would bet that is sometimes anxiety provoking and comforting all at the same time for patients.  Tell us what that feels like for patients or what your perception of that is?
Hurd             Most patients are really happy to here from Sherri and I just to hear a little bit about the facility that they are coming to, about what that visit will entail and really to try to help them see that they are going to be meeting people that are happy to walk with them as they walk this journey of a diagnosis.
Chagpar        Sherri, when the patients come to the breast center, is it true that they may meet several different disciplines? For example, they may meet a surgeon, or they may meet a medical oncologist, tell us a little bit about how you facilitate that and how you coordinate that?
Storms          Sandy and I work really closely with the new patient intake specialist.  Prior to their visit we make sure that they have their appointment set-up, they know what is going to entail, and the
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length of the visit and we get our patients in in a very timely manner looking at their diagnosis and the availability of the patient themselves and when they can come in.
Chagpar        So after that you call the patient and you tell them what is going to be happen, what their visit will be like.  What happens next?
Hurd             They are welcomed in on the date that they are coming.  We ensure that they bring everything with them when they come, we actually meet them at that visit and they are meeting with their team, their surgery team at that date, or the medical oncology team and Sherri and I try to help them understand and reflect back on the decisions that they are being asked to make and to help them move to the next step.
Chagpar        Sherri, tell us a little bit about your interactions with the physicians and the other nurses and how that all works.
Storms          Sandy and I work a lot behind the scenes making sure that the patients are getting all of their appointments and everything that they need, so we make sure that they are getting in to see the appropriate physicians if they need a breast surgeon or if they need a medical oncologist or radiation oncologist.  We help set-up those appointments for them and with plastic surgeons as well.  So we make sure that they getting in in a timely manner, and then they can call us back to let us know what their decisions are or we will reschedule them to come back in.
Chagpar        And then you also facilitate that communication with their care team, is that right?
Storms          Absolutely, either through phone calls or face-to-face interactions.  We also go to tumor boards on a weekly basis, which is the entire care team together at the same time in one room.
Chagpar        Tell us Sandy a little bit about what exactly a tumor board is and how a nurse coordinator plays a role in that process?
Hurd             We bring forward at the conference tumor board any of the patients that have a question to get a consensus from the team, from the pathologist, the radiologists, the social workers, the physicians from all disciplines are all there to discuss the best care for that specific individual patient and we are able to then from that, bring that back and discuss with that care team how to help that patient move forward in the best way for that individual.
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Chagpar        And I would imagine that from the time that you have your initial interaction with the patient and they just been diagnosed and you call them and you welcome them into the center and set-up all of these appointments, that the patients really form a connection with you, is that right?
Storms          A lot of times they do get very close to Sandy and I through our interactions, but we also try to make sure that they are comfortable with the rest of the team as well.  We start out with the patients when they are newly diagnosed and then we follow them throughout their continuum of care but we make sure that there is always someone there for them.
Chagpar        And I would anticipate that you can link them in to other resources that they may need, things like a social worker, complimentary therapy, and physical therapy.  Tell us a bit about those other services and how you facilitate that interaction?
Hurd             We do have many other wonderful complimentary services and a terrific physical therapist that works right on our floor with our patients that specializes in care of women after any kind of breast surgery or needs that they might have during their care.  We have wonderful complimentary therapies that offer all kinds of services and we have found over the years that it is a very stressful time for women as they are going through their care and sometimes in the initial stage when we are offering services, because they are trying to make such important decisions, they are not able to always hear about them, so we are there to offer them throughout their care and continue to support them as they move forward.
Chagpar        Are there other services, I know that many cancer patients often will talk about support groups and that kind of thing, are those available and how does that work?
Storms          We have two support groups for breast cancer patients, one is for the newly diagnosed and one is for the advanced breast cancer patients.  We offer that once a month and either Sandy or I attend as the nurse coordinator and then also we have social workers that are there for the support.
Chagpar        Do you find that many patients avail themselves of support groups or do you find that patients kind of feel that they have other support mechanisms either their church or their family? Where do patients get that support?  Does everybody need to go to a support group?
Hurd             Everybody does not need to go to a support group. We have found over time that for some they are able to come and get what they need from the support group and they move forward and for others they do come back because they feel that is important for them, and many women will say that they then feel that they want to help others and that is a reason, an important reason for them to return and come to support other women through what they had gone through before.
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Chagpar        That is a really interesting concept that I do not think a lot of us think about, that there is some therapeutic benefit in helping other women.
Hurd             That is definitely true. Many women do feel and have often said to us, I would love to be there for someone else as you and Sherri have been for me and for other friends or other people that are going through this journey.
Chagpar        Sherri, tell us a little bit about when the patient first comes in to see you and to meet with their care team.  How do they get information about their diagnosis?  Have a lot of them gone on the internet or is there information that is provided to them?  How does that all work?
Storms          We have developed a breast cancer booklet for patients that is really-really helpful.  Our patients are giving us real positive feedback for that and all the information is in that book.  But at the time of the visit, the physician goes through the diagnosis specific to them using the book so they can take that home and review it.  Everything really is in the book, it is very-very helpful.  There are also some internet resources in the back of the book, so Sandy and I tell patients ahead of time that  if they are researchers, and they want to look things up, there are certain websites that are better than others and they might want to stick to those websites.
Chagpar        Yeah, because I would imagine that patients who are given this diagnosis, it is often really scary, but when you go on the internet there is good information and bad information, and so you telling them which sites to go to is likely really helpful to them.
Storms          Absolutely, like the National Cancer Institute site.  We are a National Institute Cancer Center.  So with that in mind we send them to that resource and cancercare.org is another great site that we can send them to.
Chagpar        Tell us a little bit more about some of the other initiatives that you are involved in.  I understand that Sandy, you are particularly involved in something called Magnet.  What is Magnet?
Hurd             Magnet is a wonderful recognition program that is credentialed through the American Nurses Credentialing Center and we were very pleased to receive the designation here at Yale-New Haven back in 2011, and it is a program that recognizes healthcare organizations for their quality patient care and nursing excellence and innovations in professional nursing practice. It was a designation that we were looking to be able to note that we have a terrific nursing staff and team at Yale-New Haven Hospital and it is something that than the communities can note and we have decreased in hospital acquired infections and just a terrific patient satisfaction because they were able to have such a terrific nursing staff.  So, we are pleased to get that designation.
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Chagpar        Sherri, tell us a little bit more about that process.  Because it sounds like there are many hospitals across the United States that have phenomenal nursing care and so what are the things that you had to demonstrate in order to get Magnet status? Is Magnet status something that many-many hospitals get?
Storms          Not many hospitals are able to achieve Magnet status and the nurses have to be able to have a voice for themselves and not just be under regulations.  We need to have high patient satisfaction rates and continue to work on our patient’s quality of care and there are a certain number of registered nurses to patient ratio, so again at Yale we were able to achieve that.
Chagpar        And it is sounds like they looked at other quality metrics as well.  We are going to take a short break for a medical minute.
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Chagpar        Welcome back to Yale Cancer Center Answers.  This is Dr. Anees Chagpar and I am joined today by our guests Sandy Hurd and Sherri Storms.  Sandy and Sherri are both nurse coordinators working in the field of breast cancer.  Before we took our medical minute break, we were talking a little bit about Magnet and some of the quality metrics that this program, I guess this national program, has to really separate different institutions on the basis of their nursing care. Sandy, tell us a little bit about some of the metrics that it looks at both in terms of leadership as well as involvement in quality improvement.
Hurd             There are really some terrific things that have happened at Yale-New Haven as we have gone forward in our Magnet journey.  We now have a staff nurse counsel that is all nurse driven and any decision in terms of patient care are all addressed, and we use evidence based practice to try to
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move care forward and that is the nurses at the bedside that are using research and evidence to improve patient care and outcomes.  Those are some terrific things that are happening with Magnet, and the stories are ongoing, the research is ongoing, so that is a wonderful addition and improvement in our care and as well in terms of nurses themselves, they are able to go back to school or to look at clinical excellence and moving forward with their care.  Yale very much supports education for their nurses because we know that educated nurses provide the best care for the patients.
Chagpar        That is fantastic. Sherri, tell us a little about some of the quality improvement projects that you are working on.
Storms          We have been working on one in particular that is our breast cancer patient guide and we are looking at evaluating that, and that has been a new development in the breast center in the last six months.  We want to see how patients feel that it has been helpful for their care.  And we are also working on a benign booklet as well so that we can help patients that come in that do not have breast cancer, but that have benign breast disease.  A couple of the other initiatives are the patient’s satisfaction because we know that if patients are satisfied they are getting improved care.  That is one of our main improvements that we are working on right now and one of the other ones is hand washing because we know that healthcare providers that wash their hands before and after they see their patients decrease the incidence of infection.
Chagpar        It sounds like a lot of these programs, certainly the hand washing, are things that I think are becoming more and more rampant nationwide as all hospitals try to lower their infections but certainly some of the practices that you are evaluating in terms of optimizing the patient education is critical.  Tell me a little bit about research more broadly.  Sandy, do you interact with some of the research nurses and how does that work?
Hurd             We do.  I think part of our role as nurse coordinators as well as to help the patient understand all of the tools that they have at the Smilow Breast Center, is to talk about the terrific trials going on, research trials going on for patients now to advance breast cancer care and they are able to participate, and we are helping them to understand what they might be eligible to participate in, what that means for them and then to reflect back after they have spoken to our research nurses at the breast center and we bring them whatever patients might want to speak to them and then we reflect back with the patient about what that means for them, and what that mean for their care. I think that is important to them because they are getting so much information at once when they come for the visits that they need to reflect back, and we have found that to be really helpful and we spend a fair bit of time on the phone afterwards reflecting about the information and that is why the guides have really been terrific and people have said that they find that to be a helpful tool for
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them and then we can also send them back to the research nurses because we do have some wonderful advances.
Chagpar        Sherri, do you find that there are a lot of patients who are really scared about clinical trials? Nationwide we hear that less than 5% of people participate in clinical trials, because oftentimes they feel like they may be a human guinea pig.  Do you find that, do patients tell you that?
Storms          Yes, we do hear that.  They want to know what the clinical trial is about, what is in it for them and what they are looking for in that clinical trial.  We do hear sometimes that patients are very nervous about it, but once they work with the research nurse they learn what the clinical trial entails.  A lot of patients will come back and ask to be involved in that study, so the more information they have, the more they tend to want to sign up.
Chagpar        Do you find that patients come in wanting a clinical trial? I have always found that there are two kinds of patients, those who say under no circumstances do I want to be part of a clinical trial and others who really recognize that people who participate in clinical trials not only tend to do better themselves in terms of their outcomes, but really have this altruistic mission to help us to advance cancer care.  Have you seen that dichotomy and what proportion of patients would you say fall into each of those two camps?
Storms          That is an interesting question.  I would say that I definitely do agree there are many people who come in somewhat skeptical and concerned about participating in a trial.  However, I have noticed over the years that women and men, but the majority of our women have become much more educated and really are interested in what is bringing care forward in 2012 and it is true that many women do participate and once all the pros and cons and the safety factors that are in place are explained, they look forward to participating in them.  So I feel like that is moving forward and people are more willing now to participate in those trials when the physician and the team are able to explain to them and sit down and take the time to help them understand what that means to them, and why they are offering that particular trial or research study for them.
Chagpar        During this conversation, what I have come to realize is that you as Nurse Coordinators really play a very central role.  It seems like you interact between intake specialists, disease teams across all disciplines, surgery, medical oncology, radiation oncology, imaging, pathology, and plastic surgery.  You also kind of have this space where you work with the research nurses and you coordinate through this whole process. Sherri, I think that a lot of people have heard the term nurse navigator.  What is the difference between a navigator or a patient navigator and a nurse coordinator?
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Storms          The difference is that a navigator will help the patient get from one area to the next and at Smilow they wanted to make us coordinators so we wanted to do much more than just navigate from one area to the other, we wanted to be there for the patient from the beginning of their diagnosis through the end of treatment helping them integrate to the multidisciplinary team members.
Chagpar        And that must take a certain amount of qualifications because I understand that sometimes navigators can be anybody, but do coordinators have to have certain skills and certain qualifications.  What does it take to be a nurse coordinator, what would I need to do?
Hurd             I would say that this is a passion of mine and of Sherri’s as well because you really are helping to look at that particular woman or man, once again men do get breast cancers, and help each individual to look at an individual and help them from their home and their life and their particular needs to move forward and make decisions that you are their person in the medical area that can help them look at all aspects of moving through that continuum.  So if it is that there they have needs in their home that are preventing them from getting the care that they need, we can help them address that and it is really to help them be educated and make their best decisions.  So, I think having some experience in terms of all realms is helpful, specifically for the breast cancer realm, we are able to both get a certification that is specific to breast care in oncology so that we have knowledge based to help them understand their breast cancer.  It is a complicated journey for women to move forward and there are many choices that they are asked to make.
Hurd             We both have a master’s degree.  Sandy’s is in public health which goes really well with this field and mine is in nursing.  So the background between our education and our experience and passion for patient care, put that together and it’s a mix for what we would want for a coordinator in breast care.
Chagpar        That sounds fantastic. Does every patient get a nurse coordinator if they come to the breast center?  Does every patient get contact with one or both of you?
Hurd             They do.  One of the things that we have tried doing at Smilow is to have all of the care teams have a consistent team roster, if you will, available to the patients that shows them who their specific care team is and so each patient does have access to the nurse coordinator.
Chagpar        Tell me a little bit about how you interact with the wider community, because I am thinking about people who are listening to the show, who are in their car driving home from Sunday dinner or sitting on the couch with their family and they are thinking about what the services are in their community, what is out there for them Sherri?
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Storms          We have a great mobile mammography program, so we do outreach going out to the community offering the digital mammography to patients and we also have a breast program, I know that you go out into the community and do talks on occasion and we give a lot of information.  We also have a website that people can go to on our Yale Cancer website to look at information there.
Sandy Hurd and Sherri Storms are nurse coordinators at the Brest Center at Smilow Cancer Hospital at Yale- New Haven. If you have questions or would like to share your comments, visit yalecancercenter.org, where you can also get the podcast and find written transcripts of past programs.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.