Smilow Cancer Hospital Town Hall | February 21, 2024

February 22, 2024

Information

Topics:

New Clinical Announcements

Kevin Billingsley, MD, MBA, and Tracy Carafeno, MS, RN, CNML

U.S. News & World Report Rankings: What do they mean and what can we do?

Kevin Billingsley, MD, MBA

Critical Policy ChangesCapacity Management & Length of Stay

Tracy Carafeno, MS, RN, CNML, and Jensa Morris, MD

Tumor Board Transition to Epic

Jennifer Watkins, MMS

Patient and Family-Centered Care Providing Social Work Support to our Patients and Families

Angela Khairallah, MSW, LCSW

ID11340

To CiteDCA Citation Guide

00:00OK. Good evening, everyone.
00:02Welcome to this Milo Cancer
00:04Hospital Town Hall for February.
00:07Thank you all for taking time
00:09to join us this evening.
00:11I'm just going to run quickly
00:13through what the agenda is.
00:15We're going to start with some
00:17announcements and recognition.
00:19Then Doctor Billingsley
00:20will be speaking about U.S.
00:22news and World Report rankings.
00:26Doctor Jensen Morris and Nina
00:27Carrasilla will be speaking about
00:29capacity management and length of stay.
00:31And then Jen Watkins will
00:33talk about our new transition
00:35to EPIC on the tumor boards,
00:37followed by finally Angela
00:39Carrera for providing social work
00:41support to patients and families.
00:44So I am going to turn it over to Kevin
00:47to walk us through some announcements.
00:50Thank you, Tracy.
00:51And I'd just like to say welcome to everyone.
00:54Lots as as usual, lots of growth,
00:57lots of development and lots
01:00of exciting things happening in
01:02Spilo and the Cancer Center.
01:04One of the things that I want our
01:07community to be aware of is that
01:10historically we have had one of the most
01:12academically productive and clinically
01:15robust Melanoma programs in the nation.
01:20But as immunotherapy has evolved as a
01:24killer in the treatment of both Melanoma
01:28as well as renal cell cancer as and in
01:32addition to some other dermal neoplasms,
01:35we have moved to a consolidation
01:38of the clinical care of those
01:41of those two groups of patients.
01:44And we have chosen for programmatic and
01:47clinical reasons to integrate them into the,
01:51what we are now calling the skin
01:54and kidney cancer clinical program.
01:56This is under the clinical
01:58leadership of Doctor Harriet Kluger.
02:01Of course,
02:02we have a renowned team of clinicians
02:05that are drawn from both the
02:07historical Melanoma program as
02:09well as the Gu malignancies program
02:11folded in under this umbrella.
02:14And as the slide says,
02:15the program better reflects the
02:18expertise of the physicians and
02:20advanced practice providers and
02:22nurses caring for patients with skin
02:25cancers in renal cell carcinoma.
02:27The department name change has of
02:30course been updated in EPIC because
02:32that's where we do all of our work.
02:35So exciting development and I think
02:38it really reflects our leadership and
02:40our growth in this these two areas.
02:42Now United as one program.
02:45Next slide please.
02:49So on NP8, we are going to be doing
02:55both infusion and blood draw.
02:57So the NP4 blood drawing teams
03:01will be moving up to NNP 8.
03:04This will be effective on March 4th
03:06with the aim of maximizing patient
03:09capacity and nursing support.
03:12Again, there will be a change
03:14within the EPIC department.
03:16The NP4 lab nursing and women's
03:18lab draw chair will move up to the
03:21NP8 vital sign and lab draw room
03:24and patients will be scheduled
03:27for these draws on NP8.
03:31I think I would just add that the
03:33women's infusion which was separate
03:35from the solid tumor on NPA,
03:36they will function as two separate
03:39entities are now all going to
03:41be one large infusion center and
03:43that will be one department as
03:45in within this structure change.
03:50Thank you, Tracy. Next slide.
03:55So one of the other things that is
04:00incredibly exciting and
04:02rewarding to see is growth of our
04:05multidisciplinary clinical programs.
04:08Here as almost everyone
04:12in the audience knows,
04:14with Doctor Taraga's arrival over a year ago,
04:18we have become a regional and
04:20national leader in the treatment of
04:22patients with peritoneal malignancies.
04:25And this this program has actually
04:29expanded to encompass the
04:31multidisciplinary treatment not only
04:34of patients with peritoneal disease,
04:36but a spectrum of patients with complex
04:39oligo metastatic disease that we are
04:42now treating with a combination of surgery,
04:44systemic therapy and in some
04:47cases radiation therapy.
04:50As such, this complicated group of patients
04:55merits their own multidisciplinary
04:58treatment conference for prospective
05:00review and treatment planning.
05:03So we will be starting the oligo,
05:06the peritoneal oligo metastatic
05:08case conference on Fridays.
05:11This will be Friday 12:30 to 1:30
05:14under the leadership of Doctor Taraga.
05:16Of course,
05:18with other multidisciplinary
05:20teams participating.
05:21This will be virtual and
05:25it will be starting well.
05:30I think we were looking at the 23rd,
05:32but this will more likely start
05:34the 1st of March.
05:36As always,
05:37I'd like to thank the services
05:39that support these conferences,
05:42particularly Radiology and
05:44Pathology who are key members of
05:47these teams and without their
05:49support this would not be possible.
05:52This will be a case conference for now.
05:54As this evolves,
05:56we there's a very high likelihood this
05:58will evolve into a formal tumor board.
06:01To do so will require a couple
06:05of other administrative maneuvers
06:06and it will be recognized by our
06:09cancer committee and become part
06:11of our Coc structure.
06:13But for the current time,
06:14it will be a prospective case conference
06:19next. It gives me great pleasure to
06:24recognize the work of our thoracic surgeons.
06:27Under the leadership of a doctor,
06:29Dan Boffa, the STS is the primary
06:33national body who organizes A prospective
06:38data collection and quality programs.
06:42They oversee the collection of data through
06:46the STS thoracic database and our team
06:50has been awarded in the esophagectomy
06:52program with a three star overall
06:55composite for excellent performance.
06:57So obviously like all of these achievements,
07:01there is an incredible array of
07:03people who are behind the success
07:06in addition to the leaders.
07:08Obviously, it's a great recognition
07:11for our surgeons,
07:12but it could not be done without
07:15outstanding nursing care.
07:17I think it's a particular opportunity
07:21for us to recognize the work of the
07:24NP15 nursing teams who have gained great
07:27competence competencies in the care of
07:29this complicated group of patients as
07:32well as the ICU nurses and a variety
07:36of other teams that support the care
07:39of these really involved patients,
07:41respiratory therapy,
07:43physical therapy and nutrition among others.
07:47I think we can go on
07:51as we're all aware,
07:52virtually every month has some particular
07:56awareness in the cancer universe.
08:00I would say we all need to be aware
08:03of every malignancy every month,
08:06but we will give a shout out
08:09in March and ask that we dress
08:12in blue in in recognition of
08:17colorectal cancer awareness next.
08:21So I'm going to speak for a minute about U.S.
08:23news in a World Report.
08:25You know these,
08:26this is our cancer program reading.
08:29It's also our hospital ranking
08:31And I'm going to say at the
08:33outset that the health system,
08:35particularly under the
08:37leadership of Deb Rhodes,
08:39Corey Champo and Chris Petker have
08:42led incredible work that I think
08:44is going to favorably impact our
08:47ratings over the next couple of years.
08:50But this is work that requires deep
08:52and ongoing and investment and we
08:55don't see the returns immediately.
08:57I will share with this group
09:00that the house that Yellow Haven
09:03Hospital mortality scores have
09:05improved substantial substantially.
09:08I see Doctor Morris smiling.
09:11You have been a part of that.
09:12Thank you very much.
09:14You and your hospitalists.
09:17We will delve into that data in more
09:19detail in coming weeks and months.
09:22I'll just offer a teaser today and the
09:26mortality statistics in as measured
09:29by Visient and our ODE ratio is
09:33probably the most important metric
09:36that will impact our our ranking.
09:39There are other things,
09:40but that's probably the central.
09:45I wanna bring this to the
09:47attention of our community today.
09:49However, because the reputation
09:52scores are part of our ranking and
09:56our reputation scores are developed
09:58on the basis of Doximity voting by
10:02cancer clinicians across the country,
10:05it is important that we all
10:09participate in Doximity voting.
10:11Physicians and APPSI know can register
10:15for Doximity at through the app.
10:19I would encourage you if you do not
10:21have the app on your phone, it is.
10:23It's well worth having.
10:25I use the Doximity dialer all the time.
10:29I think that that's a side benefit,
10:31but it is the portal that is is
10:34that we need to have available
10:37to us to enter our vote.
10:40You can use this QRS code watch
10:43for emails from your departments.
10:45Their Cancer Center will be sending them
10:47out as well as departments of medicine,
10:49surgery, and others.
10:52As Renee points out,
10:53even if you don't see the e-mail,
10:54you can still vote.
10:56Vote by logging on to doximity.com
10:58and the survey.
10:59We'll ask users to name the
11:01hospitals that provide the best
11:03care in your respective specialty.
11:06You can list up to five.
11:07However,
11:08you only need to vote for one
11:10to have your ballot count.
11:12I will say that it is well,
11:14it is incredibly important
11:16for all of us to participate.
11:19The greatest,
11:21the most heavily weighted scores
11:24in reputation come from votes from
11:28people outside of the organization.
11:31So part of our work is encouraging
11:35colleagues and peers at organizations
11:38across the country to recognize our
11:41great work and think of us as they
11:46complete their Doximity voting.
11:51Every vote counts. I'll leave it at that.
12:01So Tracy, you're on mute.
12:02I think I'll kick it over to you.
12:04Thank you for the mute reminder.
12:07Thank you, Kevin.
12:08We are now going to turn it over
12:10to Doctor Jensen Morris and Nina
12:12Caracillo who are going to talk
12:14to us about capacity management
12:16and length of stay a very another
12:18important part of our mission here.
12:25Great, thank you and thank you
12:27for the opportunity to talk about
12:29inpatient capacity management.
12:31This is a lot of what we do
12:33every day on the inpatient side.
12:36Here's the problem,
12:37as most of you know access to
12:40inpatient care is at a premium.
12:42On any given day,
12:44we could have 80 to 100 patients
12:46who are in the emergency department
12:48admitted waiting for a bed upstairs.
12:51And it it goes without saying
12:53that Ed boarding presents a
12:54significant risk to our patients.
12:55But the literature actually supports this.
12:58Admitted patients waiting for beds
13:00upstairs simply do not receive the same
13:02level of care in the emergency department.
13:04In fact,
13:05the their median length of stay is
13:07extended almost exactly by the amount
13:09of time that they spend boarding in the Ed,
13:11suggesting that the time spent in
13:14the Ed is the care is not moving
13:17forward during that time.
13:18But worse than that,
13:20Ed boarding increases the risk of medication
13:22errors and preventable adverse events.
13:25Unfortunately,
13:25we see this in our quality
13:27and safety reports.
13:28Everyday boarding time greater than six hours
13:31actually increases in hospital mortality.
13:34There was a recent study that showed
13:36that patients who spend a night in
13:38the Ed waiting for a bed have a 1.3
13:41fold increase in inpatient mortality.
13:44That's concerning,
13:45but for older patients that is
13:48actually increases to about a
13:50two fold increase in mortality.
13:52So for older vulnerable patients like ours,
13:56spending a night in the emergency
13:58department is a highly morbid
14:00experience and potentially increases
14:02their inpatient mortality.
14:03And as you can see the the this
14:05is borne out in the literature and
14:08multiple references here as well.
14:13As a result, a lot of the work that we do
14:15upstairs is around discharge optimization.
14:18The concept is that in reducing
14:21inpatient length of stay,
14:23we can open up beds and allow these patients
14:26waiting in the emergency department to
14:29start their care sooner And on the days
14:32when patients are ready for discharge
14:34instead of discharging at 4:00 PM,
14:36move that discharge time earlier. So again,
14:39patients who are downstairs on its stretcher,
14:42staring up at fluorescent lights can come
14:46upstairs sooner and start their care.
14:49So is there evidence to support
14:51discharge optimization work upstairs?
14:52Does it actually work?
14:54And the answer is yes.
14:56Early discharge decreases the
14:58time patients wait in the Ed.
15:01For an inpatient bed discharge before
15:04noon specifically results in earlier
15:06median arrival time of admissions and a
15:08decrease in high frequency admission peaks.
15:10So instead of all the patients
15:12kind of arriving as a bolus,
15:14kind of as those discharges
15:16all happen around 4:00,
15:17the beds get cleaned,
15:18the patients arrive between 5:00 and
15:217:00 PM right around change of shift
15:23right when sort of the staffing is
15:26perhaps unstable or there are fewer
15:29doctors available to provide the care.
15:32By moving the discharge early
15:35discharges earlier in the day,
15:37we can actually smooth those admission peaks,
15:39care for patients promptly when they arrive.
15:43This has not only been shown
15:44in the medical literature,
15:45this has been shown right here
15:46at Yale New Haven Hospital.
15:48When the Yale New Haven Medicine
15:50service improved 11:00 AM discharge
15:52rate to greater than 20%,
15:54the all Ed admissions arrived
15:57one hour earlier.
15:59So the entire medicine service improved
16:01their discharge time and everyone benefited.
16:05Likewise,
16:05when hospitals were introduced
16:08to Smilohem OC services,
16:10we saw a length of stay reduction of
16:13one day on the that patient's cert on
16:16those services and it resulted in more
16:18than 500 additional patient admissions
16:20during that year to the SMILO Tower.
16:23So by reducing length of stay,
16:25we were actually able to see more of
16:27our patients on Tower instead of those
16:30patients rolling over and being seen on
16:32other units throughout the hospital.
16:33So this helps our patients get
16:36the multidisciplinary specialized
16:38care that they need on Smilo.
16:40People always ask,
16:42but you know what about patient satisfaction.
16:44And again,
16:45it's actually not impacted
16:47by early discharge efforts.
16:49Now we read all the patient satisfaction
16:52surveys and the number one complaint,
16:54not surprisingly, is meals.
16:56It's the food.
16:57The number 2 complaint is the
17:00discharge process.
17:00People say the team told me
17:02I was ready to go at 7 AMI,
17:05waited until 3:00 PM for discharge.
17:08When patients are ready to go,
17:09they want to leave.
17:11So this is actually a great
17:13patient satisfier.
17:15This is so important at Yale New
17:17Haven that seven out of eight of our
17:21inpatient priority workstream Metrics
17:23Centre round discharge optimization,
17:25these are Yale New Haven Health System
17:28priorities and seven out of eight
17:31are about discharge optimization.
17:32And I'm so I'm going to bring Nina in here.
17:35She's done a ton of work on this on
17:37her inpatient units and she'll discuss
17:39each of these inpatient metrics.
17:42Thanks, Jensa. So these are the
17:44metrics that we're working on for
17:46the fiscal year of 2024 and this
17:48shows our goal for the upcoming year.
17:51I think the inpatient teams have
17:53really been working hard to improve
17:56discharge optimization and as Jensa
17:58had said or Doctor Morris had said,
18:01the the majority of the metrics
18:03are related to discharge.
18:05So it's important for the nurses,
18:08the providers, the Care Coordination,
18:10care coordinators to all work together
18:13to really improve these metrics.
18:15So just to briefly go through them all,
18:17I think the one that we're most
18:19aware of and comfortable with is the
18:21percent of 11:00 AM discharge and
18:23this is the percent of discharges
18:26completed before 11:00 AM.
18:28The goal for this year is 18%.
18:31Some of the other ones,
18:32which we're starting to improve slowly,
18:36are the expected discharge date.
18:39This is the percent of
18:41inpatient hospital day,
18:42inpatient hospital days with a
18:45documented expected date of discharge.
18:48So we're the care coordinator,
18:50the provider.
18:50We can try to get an expected date of
18:53discharge that everybody's aware of.
18:55And then our goal is to get the
18:58patient out by that particular date.
19:01The percent of daily discharges are
19:03the percent of days in which each unit
19:06meets their daily discharge target.
19:08And so that's by unit,
19:09and that's set by an epic algorithm.
19:12The overall goal for this year is 65%.
19:16And then we can try to break that
19:18down between weekdays and weekends
19:19to see if we can meet that through
19:22the whole entire week.
19:23As sometimes weekends tend to be a
19:25little bit more challenging for discharges,
19:27we're trying to figure out what the
19:29barriers are to that and trying
19:31to improve how we can improve
19:33our weekend discharges.
19:35The percent of CMO patients
19:37discharged to Hospice,
19:39that is the percent of patients that have
19:42ACMO code status that have a disposition
19:44to Hospice whether it be home Hospice,
19:47inpatient Hospice with the
19:49goal of 55% for this year.
19:51We're trying to increase and improve
19:54Hospice utilization for patients.
19:57And then lastly,
19:58the ODE length of stay which is the
20:01actual or observed length of stay
20:04compared to the expected length
20:06of stay as determined by their the
20:09as the coding of their prognosis
20:11and diagnosis and comorbidities.
20:13And so these are the metrics that
20:16I think now we're really trying on
20:18a day-to-day basis try to improve
20:20in improve discharge optimization.
20:23Thanks. Thanks, Nina.
20:29So how are we doing with
20:31our discharge metrics?
20:32So you can see the metrics here on the
20:34left under the priority work stream.
20:36You can see the Yale New Haven
20:39Health System goals in blue.
20:41And then you see Smilo and you say,
20:43hey, we're doing pretty well,
20:44we're in the green.
20:46And you know, if you really wanted
20:48to look for our opportunity,
20:49it's weekend discharges.
20:50In fact, a patient said to me today,
20:54I I just have to be out by the weekend,
20:56'cause you know what happens on the weekend?
20:58Nothing.
20:58And we don't want to be a five
21:01day a week hospital.
21:02We need to be a seven day a week hospital
21:05providing services equally on all seven days.
21:08So it looks like from a
21:11distance we're doing well,
21:12but actually what when you break
21:14it down by unit and by service,
21:16we have some really high performing
21:18units and then we have opportunities.
21:20And so just to give some shout
21:22outs and to point out where we
21:24have opportunities to improve
21:2511:00 AM discharge NP12 solid
21:28tumor oncology and NP 14,
21:30Nina's unit gynecology oncology is doing,
21:34they're both doing exceptionally well there.
21:36We have opportunities on Smilo
21:39East and hematology and P11,
21:41expected date of discharge documentation.
21:44NP12 has a lot of work to do and
21:46that's the unit I spend the most time.
21:48And we really need to be able
21:50to get everyone on board so that
21:53we're communicating clearly to
21:54the patient and their families
21:56percent of daily discharges.
21:58Again,
21:59it's Nina's unit that's carrying
22:01all of Smilo and the rest of us
22:04need to catch up on achieving
22:06our daily discharge targets,
22:08patients CMO patients discharged to Hospice,
22:11The most opportunities are both
22:13on hematology and then on surgical
22:16oncology and P-15 and O to E length of
22:21stay are opportunities are really on
22:23hematology and solid tumor oncology.
22:25So just to let you know that although
22:27that we're meeting the targets,
22:28there's still work to be done
22:31on the individual units.
22:32And so in conclusion,
22:34we really wanted to emphasize here
22:36that inpatient beds are a scarce
22:38resource requiring responsible resource
22:40stewardship just the same way we
22:42do blood management stewardship,
22:44antibiotic stewardship,
22:45We need to use our inpatient beds wisely.
22:49And one of the ways we need to do that
22:51is to reduce inpatient excess days.
22:53We would never suggest discharging a
22:55patient before they're medically stable.
22:57The goal is to reduce the days
23:00beyond medical stability and
23:02when patients are ready to go,
23:04they want to go home and that's
23:06up to us to discharge earlier.
23:08You may hear your patients talk about
23:10the closer to home discharge lounge.
23:12So patients who are medically ready
23:14and they're just waiting for a ride
23:17may go to the discharge lounge just
23:19outside the atrium on the 1st floor.
23:22We will continue as we have been
23:25for really decades now shifting
23:27clinical burden to the outpatient.
23:30So non critical evaluations,
23:32staging scans,
23:34biopsies that don't need to be done.
23:35Inpatient unfortunately will continue
23:37to be shifted to the outpatient.
23:39And we know that increases the burden
23:42on the outpatient providers and you
23:44know increases care coordination and
23:49but again it allows the patients who are
23:51critically ill in the emergency department
23:53to get the care that they need upstairs.
23:56We need to use a hospital at home
23:59more broadly, either patients being
24:01transferred directly from the Ed to
24:03hospital at home or patients spending
24:04a few days in the hospital and then
24:06transferring to hospital at home.
24:08This is a service patients love universally.
24:11Patient satisfaction levels at hospital at
24:14home exceed patient satisfaction anywhere
24:16else in the brick and mortar hospital.
24:18And then one other point to emphasize
24:21is that the concept of virtual Hospice,
24:23so using inpatient beds for Hospice
24:26care is really not an option.
24:29We need to use those beds for again are
24:33critically I'll patients and so patients
24:35who are transitioning to in to Hospice care,
24:38ideally that would be done as an
24:41outpatient but we know that's not always
24:43possible and when we do do that as an
24:45inpatient we'd be transitioning to
24:47inpatient Hospice units or home Hospice.
24:51I would love to entertain questions.
24:55This is this is work that we is ongoing
24:58and we it's all about improving
25:01access for our patients.
25:10If anyone has questions they
25:11want to put in the Q&amp;A or chat,
25:21you know Jensen and Nina,
25:23I'll just first start by saying thank you,
25:25thank you, thank you.
25:27This is incredibly important work
25:29and it does make me very proud
25:31of our teams to see the progress
25:33that we are making across the
25:35units under your your leadership.
25:38As you both pointed out, it is,
25:41this is a totally team based endeavour
25:47requiring a lot of coordination,
25:52collaboration and aligned messaging
25:55from attending physicians, surgeons,
26:00advanced practice providers,
26:03residents, fellows and of course
26:06our our nursing teams. And
26:10you know I think we all
26:11have a part to play in it.
26:12I do have questions.
26:14I'm going to save them till the end.
26:16I think we will have a
26:17little time for Q&amp;A although
26:22there Jensen might have to
26:24leave a little bit early.
26:25Sorry. There is one question,
26:27why do we take Diane's question then?
26:31So the question is getting people who
26:33don't qualify for inpatient Hospice and
26:35can't go to home Hospice and don't have a
26:37payment source for Hospice in short term.
26:39Rehab is a huge, huge problem we
26:42encounter on very regular basis.
26:44It needs, I think it's a comment
26:45more than a question.
26:46It needs advocacy on governmental
26:48level to expedite Title 19 for long
26:51term care application approvals.
26:54I couldn't agree more.
26:55Diane, I'm I'm right with you.
26:57This is a huge problem.
26:59Access to *** level Hospice is really
27:02limited and this is a struggle for
27:06our families to figure out ways to
27:09support their loved ones at home.
27:15The options are so limited right now
27:25Jen. So I will follow up on that
27:27I guess with one one question.
27:29I know Scott Sussman and other
27:32leaders in the health system are
27:35doing their best to identify some
27:38alternative resources within
27:41the system for folks who require
27:46essentially inpatient Hospice care
27:48but just don't have other options.
27:51And I know Grimes was something
27:53that was being investigated at
27:55least as an option where do can can
27:59you give our community any updates
28:01on where those efforts stand?
28:07The it's still a challenge and what
28:12Diane is referring to is that when
28:16someone transitions to Hospice care
28:22they need a separate payer
28:23if they go to long term care.
28:25So they need Medicaid as a payer and
28:28they need and then they Medicare pays
28:31for their Hospice part of the benefit.
28:34So it's fairly limited access
28:36and patients have to private pay
28:38for their room and board if they
28:40don't have the Medicaid benefit.
28:42It's complicated.
28:43So yes, Scott Setzman and others are
28:46looking to see if this is a partnership
28:48that we as an organization could
28:50support and we're not there yet.
28:52We do have an announcement about
28:54Yale New Haven Home Care Plus.
28:56So that is our home care agency that
28:59provides Hospice at home without the
29:02requirement for full 24 hour care,
29:05which is sometimes a barrier for families.
29:07So it just opens up a little
29:09more options for our families.
29:11But again this is an ongoing struggle.
29:14Jenza any I have not heard,
29:17but I know there was ACMO unit
29:20opening up on SRC campus.
29:22Do we ever utilize that for our patients?
29:24So again, unfortunately,
29:25yes, we have ACMO unit,
29:27they do great work there.
29:29It's run by our palliative
29:31care service over at SRC,
29:34but here's the issue, they work on
29:37transitioning patients to Hospice.
29:40And so it's a transitional unit.
29:42It's still acute inpatient
29:43beds that again are a premium
29:45resource and because they're,
29:47they work on transitioning
29:48patients to Hospice,
29:49very often what happens is families
29:52will say you know if they could
29:54be transitioned to Hospice,
29:56let's just do it.
29:57And so we don't,
29:58it's not an optimal resource
30:00for us here in Smilo.
30:08And and again Diane's right, it it the
30:12limited utility for us here in SMILO. OK,
30:20right. Well, thank you both.
30:21Excellent presentation with a lot
30:23of very important information.
30:26We are now going to transition
30:28to the transition of tumor board to EPIC
30:31with Jennifer Watkins. Welcome, Jennifer.
30:36Thank you. All right,
30:37let me just share my screen.
30:42All right. Can everybody see?
30:46Wonderful. OK. So I'm gonna really
30:51just show a few two or three slides
30:53and just kind of give a high level,
30:55but I, I am happy to to go into further
30:58details if there's any questions.
30:59But essentially we spent the
31:02last year or so really undergoing
31:05A comprehensive assessment and
31:07review of the tumor board process.
31:10We've, we've listened to a
31:12lot of of the the physicians,
31:14we heard the complaints,
31:15we heard what was working well,
31:16what wasn't and we were able to
31:18kind of really focus in on three
31:21key improvement opportunities.
31:22So really streamlining the
31:24CME accreditation process,
31:25optimizing the workflow and
31:28increasing our HIPAA security.
31:30So really this is, this is the money slide.
31:33So what is changing,
31:34we are going to be streamlining
31:36the CME accreditation process.
31:38So I've heard from basically
31:40every tumor board director,
31:42what a pain point this has been.
31:44So we will now have a single CME
31:47application that covers all tumor boards.
31:49It will not require the tumor
31:51board director and their admin
31:53to complete and submit.
31:54We will take take that on within
31:56my team and it'll continue to
31:58allow for the individual CME
32:00codes for each tumor board.
32:01Nothing really changes but the the
32:04painful re accreditation process
32:06every year will no longer be put
32:09on the burden of the the tumor
32:11board directors and their admins.
32:12The the biggest piece I think is
32:14really the workflow optimization.
32:16So thanks to a lot of wonderful help
32:20from our our EPIC optimization team,
32:22we have been able to build the
32:24infrastructure to transition all of
32:26the tumor boards into EPIC which
32:28is going to really increase our
32:30automation and reporting capabilities.
32:31So essentially they have built,
32:34they've created a YNH Smilo tumor
32:36board department and every tumor
32:39board is built as a resource.
32:41And so we will be able to utilize
32:43the current tumor board referral
32:44to schedule patients within their
32:46the tumor board clinic.
32:48Physicians will be able to pull
32:49up the tumor board agenda within
32:50the clinic schedule view.
32:51So really the the big piece for
32:53this that that people will notice is
32:56that traditionally we have emailed
32:58out an excel agenda every week
33:00some at some point over the next
33:02month or two we will be phasing
33:04that out and everyone will be able
33:06to to go into EPIC to see their
33:08the upcoming tumor board schedule.
33:10To be clear that it's already in
33:11EPIC that is already happening.
33:13We are just also sending the Excel
33:16agenda just as we get everybody comfortable,
33:19everybody set up,
33:20but you are able to go into EPIC
33:22today to see your patients.
33:24This creates ability for easier
33:26documentation for anyone who's
33:28interested which I I will briefly
33:29touch on in a minute and really just
33:31allows for increased scalability as
33:32additional tumor boards are created it.
33:34It also just makes such a much more
33:37efficient workflow and it keeps all
33:39of the patient information within EPIC.
33:41The third piece is was really
33:43run HIPAA security.
33:44So previously all tumor boards utilized
33:46the same as new link which is at more of
33:49a risk if if the link becomes compromised,
33:51all the tumor boards are compromised.
33:53So the recommendation from the
33:55privacy office was to individualize
33:57the zoom links and to update to a
33:58new link on on an annual basis.
34:00The the really big perk here is it
34:02finally will allow tumor boards to
34:04overlap or to run parallel you know to
34:07historically pre COVID tumor boards were
34:08in in person so we were only able to
34:11have one tumor board at a time in the room.
34:13Now that many tumor boards have have
34:15decided that virtual works better for
34:17for them where it'll it'll allow us to
34:19be a little bit more flexible scheduling.
34:21That being said,
34:22some tumor boards are our hybrid and
34:24and we have the ability to bring anyone
34:26back in person if that's what the
34:28group is interested in and then just
34:30request for all participants cameras to
34:33to be on to use the the proper name on there.
34:36Thursday the name tag
34:39to give a a quick look at what
34:41the epic agenda will look like.
34:43So all of the columns that that
34:47existed on the excel spreadsheet are
34:49now pulled into your tumor views.
34:51So just like you would go here to
34:53see your schedule for clinic with a
34:56few quick steps we can get you set
34:58up with a tumor board schedule built
35:00here and you'll be able to click on
35:02it and see your upcoming patient.
35:03So it brings in the question for the
35:05tumor board and the imaging that you'd
35:07like presented pathology staging,
35:09all that's here.
35:10We also have a nice tumor board data report.
35:12So when you highlight a patient,
35:13it pulls in all of the last five
35:16years of imaging,
35:17pathology and irrelevant oncology
35:19logic history.
35:21So it really brings in a nice
35:23summary down here as well.
35:24You can also easily go to chart review
35:26from the screen or you can double
35:27click on the the patient the same
35:29way you would if you were seeing them
35:31in clinic which would open up the
35:33encounter in the charting workspace.
35:35This is really only for anyone
35:37who is interested in utilizing
35:39the documentation functionality.
35:41But if any of the teams are,
35:43we have created flow sheets both
35:46for kind of a general tumor board
35:49as well As for each individualized
35:51tumor board and then that that
35:53pulls into a note template.
35:54So we can in we can optimize this,
35:57we can individualize this.
35:58Some of the other teams GI
36:01specifically with rectal cancer has
36:03really taken advantage of being able
36:05to to individualize their notes.
36:07So we have the ability to really
36:09make this work for you.
36:10Again,
36:11this is just available for
36:12anyone who's interested it.
36:14It does not have to.
36:15This is completely locked
36:16down from the patient.
36:18They do not see that they are scheduled.
36:20They do not see that there is a note,
36:21nothing goes through my chart.
36:24The other it is visible to
36:26anyone on the care team.
36:27So any other provider can see the note,
36:29but it is also not part of
36:31their legal medical records.
36:32So if records were ever requested
36:34or subpoenaed,
36:35the tumor board documentation
36:37would not be a part of it.
36:39So that is really the,
36:42the changes in a nutshell.
36:44I will say you will see over the next
36:47few weeks cancellations coming from
36:49the existing tumor board invites as
36:52I send out new invitations with the new,
36:56with the new links.
36:57We have moved all of the tumor board invite
37:00lists over to listservs within Outlook.
37:02So if for some reason you are
37:04you want to be on the tour board
37:06and you're not included,
37:07please let me know.
37:08We can absolutely make that change.
37:10But I believe everybody that is currently
37:13on the invite list has been transferred over.
37:15So hopefully this should be a
37:17relatively seamless transition.
37:18Does anyone have any specific questions?
37:22I will be making the rounds with
37:24individual faculty meetings,
37:26section meetings.
37:28I'm meeting with the various chiefs
37:29and directors to get everybody set up.
37:31We do some tip sheets that will be going out.
37:33So there is a lot more education coming.
37:36But this is just kind of to
37:37give everybody a heads up.
37:45Jen, thanks for sharing this.
37:48You and I have been kind of
37:50communicating this roll out.
37:51I think it's exciting.
37:53It is a change as with all change you
37:57know there there is an adjustment.
37:59It will be a different workflow
38:01for people and you know one of
38:03the differences is I think many of
38:06our clinicians have gotten pretty
38:08accustomed to the tumor board roster
38:10appearing in their e-mail in basket.
38:13It will require us to engage
38:15with EPIC which we all do on a
38:18virtually daily basis any anyway.
38:23So I I'm excited about it.
38:25I think the ease of the CME,
38:29the documentation function and the
38:34I can't overstate the importance in
38:38this era of privacy concerns and cyber
38:44vulnerabilities maintaining the most
38:50active and HIPAA compliant platform.
38:54You know I I will the the the stories
39:03of health systems being brought to
39:06their knees by cyber intrusions and
39:10leaks of patient privacy information
39:14are significant and it is important
39:18that we take every effort to to
39:20protect our patients privacy and I
39:22think that that you mentioned that
39:24but I I just want to repeat that.
39:26So thank you for joining us today
39:28and and Jen you did get some shout
39:31outs in that chat and then the one
39:33question which I see you answered
39:34so it but just for everyone their
39:36question was will there be a Zoom link
39:39accessible from Epic or a separate
39:41invitation and it will be still come
39:43through an e-mail outlook calendar
39:45correct it'll it'll still nothing changes
39:48about the way you will see the invitation.
39:51So it'll you will just get a
39:53cancellation over the next few weeks
39:55while I'm phasing out the old Zoom
39:57links and setting up the new ones.
39:58But then you'll have the the request
40:00that comes through the outlook and
40:01and we'll be right on your calendar.
40:06Right. Thank you. Thank you.
40:08Now we are gonna transition over to
40:11talk about social work to our support
40:14to all of our patients and families.
40:16Angela Corella is gonna walk
40:18us through this presentation.
40:20Welcome, Angela.
40:22Thank you, Tracy.
40:22Let me just share my screen.
40:35OK. All right. So it's an absolute
40:38pleasure to be here tonight.
40:41I'm talking to all of you for just a
40:43few minutes about patient and family
40:46centered support and the types of social
40:48work services that we provide to our
40:51patients and our families. Angela,
40:52I don't know if you could just
40:54switch it to presentation mode.
40:56I did it. Isn't that bizarre?
40:59At the top, if you hit Display settings,
41:02it should give you an option to switch.
41:05Give me a second display settings. OK.
41:12And then swap to Presenter, View,
41:15Q. Thank you for that one.
41:17One monitor it was that way.
41:19On the other monitor,
41:19it was the other way.
41:20So thank you for pointing that out.
41:22All right. OK. So let's begin.
41:26So I thought it would be really
41:28important for us to talk about what
41:30exactly an oncology social worker is,
41:32because some of you might not really know
41:34what an oncology social worker is all about.
41:37So all of us are licensed professionals who
41:40provide counseling and emotional support as
41:42well as access and services to resources
41:45to our patients and our families and our
41:48caregivers who are impacted by cancer.
41:50And we're educated and we're skilled
41:52in being able to identify the social,
41:54emotional, physical and spiritual
41:56issues that can come up as a result
41:59of cancer diagnosis and treatment.
42:01And we're there to support families from the
42:03time of diagnosis through cancer treatment,
42:05recurrence, survivorship,
42:06palliative care,
42:07as well as end of life
42:11throughout the Smilo system and Care Network.
42:13I just wanted to let all of you know
42:15the different locations where we
42:16have social work services available.
42:18So Greenwich, Trumbull, Fairfield,
42:21Torrington, Orange, New Haven,
42:23of course that's our inpatient as well
42:25as ambulatory services, North Haven,
42:27Guilford as well as Saint Francis Hartford.
42:32So in order for us to talk
42:33about social work and the kinds
42:34of services that we provide,
42:35I thought it'd be really important
42:37to talk about psychosocial distress.
42:39So as defined by the National
42:42Comprehensive Cancer Network,
42:44psychosocial distress is multi factorial,
42:47an unpleasant experience of
42:49psychologic meaning cognitive,
42:50behavioral and emotional as well as social,
42:53spiritual and physical nature that
42:54may interfere with one's ability to
42:57cope effectively with their cancer,
42:58their physical symptoms as well as treatment.
43:03And when we're talking about this,
43:04it's important to know that oncology
43:06under oncology social workers have
43:08a deep understanding of the complex
43:11psychosocial issues and the stress
43:13that come about because of cancer.
43:16They know that when there's a cancer
43:18diagnosis it impacts the family
43:20significantly and it can even be
43:23quite traumatic and life changing.
43:25We know that patients and families
43:27experience different levels of distress
43:29and distress is actually quite common and
43:32normal as a result of cancer and treatment.
43:34We also are aware that adjusting to
43:37cancer can be quite difficult and often
43:39results in worries about the future
43:42regarding treatment side effects,
43:44fear of cancer recurrence progression
43:46and can often lead to things
43:49like anxiety and depression.
43:50And with thinking about that,
43:52I just want to point out that there are key
43:55distress points along the cancer continuum.
43:57And so these are different points
44:00along along along the line where
44:02it's really helpful and beneficial
44:05to have social work involved.
44:07We know that when a
44:09patient's newly diagnosed,
44:09when they start treatment,
44:11as they go through treatment,
44:13transition into ending treatment,
44:15even into survivorship,
44:16quite often they can experience a variety
44:19of distress and development of anxiety
44:21and depression and if there's a cancer
44:23recurrence or some disease progression,
44:25transitioning to goals of care or
44:27palliative care and even end of life.
44:29Again,
44:29these are key points where evolving
44:31social work support is very helpful and
44:34beneficial to our patients and our families.
44:36You know,
44:37we know that distress can negatively
44:39impact someone's quality of life,
44:40their emotional health,
44:41their ability to cope.
44:43We know again that that distress
44:45is really on a continuum and it can
44:47really be more common normal like
44:49fear and some worries and sadness.
44:52Or again,
44:52it can become more significant and
44:55develop into anxiety and depression.
44:57And social workers know how to find
44:59ways to help patients and families cope.
45:02And that really brings about
45:03an enormous sense of relief,
45:04not just to the patient,
45:05but their families as well.
45:09So what to expect when you're
45:10meeting with a social worker?
45:11Some people might not even know.
45:13So it's important to understand that
45:15social workers are part of your
45:16oncology team and we're available to
45:18assist in a wide range of issues and
45:20challenges that you might be faced with.
45:23We can meet with you one time,
45:24maybe there's some very difficult news
45:27that's being delivered by your medical
45:29team or we can be available to meet
45:31multiple times throughout treatment.
45:33But really this comes about
45:34based on your needs as well as
45:36the preferences of the patient,
45:38the family that we're working with,
45:39with how often we should
45:41be meeting with them.
45:42We're available to meet in person,
45:45talk over the phone,
45:46and we do have some social workers
45:48on our team who do provide some
45:50telehealth visits when meeting
45:51with the social worker.
45:52Often during our first visit we'll
45:54complete a a psychosocial assessment
45:56and we might even utilize some results
46:00from the iPad depression screening, the PHQ,
46:03the social determinants of health Screener,
46:05or the distressed involver when we're
46:07meeting with patients and families.
46:11So this is some of the things
46:13that we assess for during
46:15our psychosocial assessment.
46:16So we want to find out about,
46:19you know, a patient in their family,
46:20the reaction to the diagnosis,
46:22their support system, you know,
46:24maybe if there are any employment
46:27issues or financial issues,
46:29if they're having any signs or
46:30symptoms of anxiety or depression.
46:32It's important for us to understand
46:34if a patient has a mental health
46:36history or a trauma history.
46:37We of course assess for suicidality,
46:40substance use, safety issues,
46:42but also want to examine positive
46:45coping strategies and other
46:47risk and supportive factors.
46:48It's important for us to understand the
46:51holistic approach the patient again,
46:53their physical, emotional,
46:54social and spiritual impact
46:56that cancer and treatment has
46:57on them and their family.
47:01So some of these are strategies or
47:03interventions that social work support
47:05would use to address the emotional impact.
47:08Again, talking about how the patient
47:10is adjusting to their cancer diagnosis
47:12and treatment would be something that
47:14we would often be talking to you about.
47:17We provide supportive counseling
47:18not just to the individual,
47:20but to the family as well as couples.
47:23Some of our social workers might even
47:25utilize such interventions as some basic
47:27cognitive strategies like reframing or
47:29talking to the patient family about
47:31what is or maybe isn't in their control
47:34related to their diagnosis treatment.
47:36We have a variety of social workers
47:37that are actually trained in something
47:39called meaning centered psychotherapy.
47:41So that would be exploring with the
47:43patient about what brings meaning
47:44and purpose to their life as they're
47:46going through cancer and treatment.
47:48Many of our social workers are skilled
47:50at being able to talk about how
47:52to talk to children about a cancer
47:54diagnosis and treatment.
47:55That's a program that we have called packs.
47:57So parenting at a challenging time,
47:59exploring coping strategies.
48:00You know, stress management,
48:03relaxation, mindfulness techniques,
48:06sleep hygiene,
48:07these are all things that social
48:09workers would provide to you as
48:11you're meeting with them.
48:12And it's not uncommon that if you're
48:14really having a difficult time for us
48:17to maybe talk to you about exploring,
48:19meeting with the mental health
48:20provider in the community,
48:21or maybe talking to a psychiatrist
48:24for some medication management.
48:26When we're meeting with families
48:29and caregivers,
48:30of course we provide emotional
48:32support to them.
48:33We want to empower family members and
48:35caregivers to be able to advocate
48:37on behalf of their loved one.
48:39We want to help caregivers and
48:41family members navigate.
48:43Maybe they're taking time away from
48:44work or they're having to have to
48:46take time away from their own families
48:48to provide care to their loved one.
48:50We want to educate our our caregivers about,
48:53you know,
48:54about caregiver stress and burnout
48:55and the importance of self-care
48:57as you're caring for someone with
48:59cancer and support you with how
49:01to navigate those relationships
49:03and communicating with family,
49:05friends, the patient,
49:06as well as the medical team
49:08that you're working with.
49:09And it wouldn't be uncommon for us
49:11to maybe encourage or recommend that
49:13a family member or caregiver or
49:15attend a support group or maybe also
49:18seek some mental health counseling
49:19in the community themselves.
49:22One of the other things that social
49:24workers do is we connect you to
49:26different resources and services
49:27in the community.
49:28So from from Smilo,
49:29there are a variety of services that
49:31we might talk to you about or refer
49:33you to like maybe the you know Cancer Center,
49:36survivorship clinic.
49:37We might talk to you about spiritual care,
49:40talking to someone in integrative medicine
49:42maybe for yoga or massage or some Reiki.
49:45And we also have a Yale Psycho oncology
49:47program that we can talk to referring
49:49you to as well within the community.
49:51We might talk to you about
49:53financial resources to refer
49:54you to. Maybe there's some
49:55transformation needs there,
49:56housing issues, state,
49:58federal benefits, talk to you about
50:01employment or work related issues.
50:03And again if there's a need,
50:04talking to you about mental health
50:06services within the community.
50:09So this list right here is just
50:11a variety of different support
50:13groups that we run through SMILO,
50:15through the different care centers.
50:16I will say though,
50:17most of our groups are still virtual
50:19and that's a result of the pandemic.
50:21But you can see there's a variety of
50:23different cancer groups here and at
50:24the end I have my contact information.
50:26So if anyone's interested
50:27in any of these groups,
50:28you can reach out to me and be
50:29happy to connect you to the social
50:31worker that facilitates them.
50:32So again, we have breast and Melanoma
50:34and neuroendocrine, pancreatic,
50:36a lot of different options,
50:38caregiver group, you know,
50:40for patients and family members
50:42to be able to access.
50:43Now this next slide, I am so excited about.
50:46So, I'm so excited to announce that
50:49social work has been collaborating
50:50with the early onset program.
50:53And in March,
50:54we are launching 2 new support groups.
50:56We have an early onset Cancer Support group
50:59for patients between the ages of 18 and 49.
51:02And our two social workers,
51:03Hallie Robinson and Krista Madrid,
51:04will be facilitating that group.
51:06There's their contact information
51:08if anyone's interested.
51:09And we also have an early onset
51:11Cancer Support group for caregivers.
51:12So a caregiver who's caring for a loved one,
51:15who's going through cancer treatment,
51:17who's between the ages of 18 and 49,
51:19and Mary Strauss will be our social
51:21worker facilitating that group.
51:22So we're very, very excited about this.
51:24So please get the word out.
51:25Please reach out to these social
51:27workers if you're interested,
51:28And with that,
51:32if you have any questions about how
51:34you can connect with a social worker.
51:36If you're interested in speaking
51:37with one of us,
51:38you can ask a nurse, your apron,
51:40or your doctor to place a
51:41referral for social work.
51:42You can reach out to the
51:44Department of Social Work.
51:44The phone number is 203-688-2195.
51:47We can connect you to your
51:50Smilo Clinic social worker,
51:51or of course their Smilo
51:53Supportive Care Access Program.
51:55Their phone number is listed there as well.
51:57They can also help facilitate
51:58A referral for Social Work
51:59services if you're interested.
52:03And thank you so much for
52:05your time this evening.
52:06There's my name, my contact information.
52:08Again, please, please don't hesitate to
52:10reach out to me if you have any questions,
52:12any concerns, need help,
52:14directions, anything that I can do,
52:16I'm happy to help out.
52:17And with that,
52:18if anyone has any questions right now,
52:19I'm happy to take them.
52:30You know, Angela, I think I'm gonna
52:31take the privilege of jumping in
52:34with a question. One of the things,
52:37one of the areas where I I feel
52:40like I see need very acutely and
52:42it's not clear to me the best
52:45way to access your services is
52:48are in patients who are sometimes
52:53really struggling with distress.
52:56And it's complicated.
52:57Often it's a mixture of pain,
53:01anxiety, loneliness, fear,
53:05and while our nursing staff is outstanding,
53:09they sometimes just do not have
53:12the time to provide the kind of
53:16bedside support and counseling
53:19and kind of psychosocial support
53:21that some of these folks need.
53:25Can you give us a sense of what
53:27kind of availability your team has
53:30for what is essentially short term
53:33therapy for patients in the hospital?
53:36And I'm going to make it even more
53:40complicated because I see this on weekends,
53:42particularly when I'm rounding.
53:46Yeah, that is a very good question And I
53:48wish I could say that we have 30 social
53:51workers who work inpatient that can provide
53:53those services because they are so needed.
53:57We do not have social workers that are
54:00staffed on the on the weekend inpatient.
54:03And so that is not something that
54:05we have available at this time,
54:06but it is absolutely a need.
54:08You know, I wish that we had millions
54:11and millions of dollars, you know,
54:12to be able to hire inpatient social
54:14workers so that they truly could spend
54:16the amount of time that a patient and
54:19family needs when there are experiencing
54:21that significant level of distress.
54:23And I think, you know,
54:24often times it's in a matter
54:27of prioritizing the priorities.
54:28You know,
54:29they have all these competing priorities,
54:31you know, when they're on a floor.
54:32And so sometimes they really are well
54:34intended to be able to spend a good amount
54:37of time with a patient and a family member.
54:40But then some safety concern
54:41comes up or you know,
54:43there's some kind of a crisis down
54:44the hall and they get pulled into,
54:46you know, a million of directions.
54:49And so I think they're all very
54:51well intended and I can speak,
54:52I know that that the inpatient
54:54social workers wish that they had
54:56that ability to be able to spend
54:58the time that patients and families
55:00deserve in being able to provide,
55:02you know, that level of support.
55:06Angela, just to Kevin's question
55:08about weekend coverage,
55:09what is the coverage for
55:11inpatient on weekends currently?
55:13So currently right now,
55:15if something does arise or come up,
55:17we do have staff within the
55:19Yale New Haven Hospital system.
55:21We have social workers
55:22that do weekend coverage,
55:23that work on weekends.
55:24And so if there's a safety concern
55:26or something that comes up,
55:27they can always be contacted
55:29and they will come over and
55:31see our patients at Smilo.
55:39I think there was a question from Doctor
55:43Taraga about social workers in the clinics.
55:46I mean I think we might want to share.
55:48You know that Angela has recently taken over.
55:50I think you saw that on the slide as the
55:53interim manager for oncology social work.
55:55And one of the charges Angela will be has
55:58is to really look at the scope of social
56:00work across the entire Smilo enterprise
56:02and sort of come up look at where we
56:05have gaps and needs and and basically
56:08propose how we're going to manage that.
56:10So that is some of the work Angela
56:12will be doing and we and some
56:14of you might get tapped on.
56:15We are going to kick off a work group
56:19multidisciplinary to assist in some of
56:21this work of you know really identifying
56:23the social workers roles within SMILO.
56:34Thank you, Angela.
56:35No, thank you. Pleasure.
56:40Kevin, do you want to close this out?
56:43I think I would be happy to.
56:45I just, yeah. I think we're at
56:48the hour. No other questions.
56:52I think I'll just close with our
56:54usual note of gratitude. And I also
56:57want to thank all of our panelists.
57:00I know gents had to drop off,
57:02but you know the work you all are
57:06doing is impactful for patients,
57:08teams and families in the organization.
57:10So we're all indebted.
57:13Have a great evening everyone. Thanks.