Hop­kins ex­pands ur­gent care

‘A big gap is be­ing filled’ with cen­ter specif­i­cally for can­cer pa­tients

Baltimore Sun - - FRONT PAGE - By Mered­ith Cohn

Most can­cer pa­tients go­ing through treat­ment strug­gle with pain, fevers and nausea, some­times se­vere enough to send them to the emer­gency room.

But the chaos of the emer­gency room and re­lated stress are “an as­sault on your well-be­ing,” said Richard Dean, who took his wife many times while she was bat­tling ovar­ian can­cer six years ago. He told Johns Hop­kins Hos­pi­tal of­fi­cials they needed an ur­gent care cen­ter espe­cially for can­cer pa­tients.

“Any­one who gets can­cer dis­cov­ers it’s just a messy dis­ease,” Dean said. “Your white blood count runs down, you get a fever, and you’re at re­ally high risk for in­fec­tion and you go sit for hours in a wait­ing room with a bunch of kids with the flu.”

Hop­kins lis­tened and, us­ing some pa­tient data crunch­ing from Dean, who teaches en­gi­neer­ing at Mor­gan State Univer­sity, launched a can­cer ur­gent care cen­ter in 2014 in space ad­ja­cent to where chemother- Sharon Krumm, di­rec­tor of nurs­ing ad­min­is­tra­tion, left, and Kris­ten Reeb, an ur­gent care nurse prac­ti­tioner, help care for can­cer pa­tients at the Hop­kins Kim­mel Can­cer Cen­ter.

apy is de­liv­ered. The Hop­kins cen­ter is open 12 hours a day dur­ing the week and plans to open on Satur­days start­ing in March.

Pa­tients typ­i­cally don’t walk in, as they do with nor­mal ur­gent care cen­ters, but call a hot­line and are told to come to the cen­ter if the nurses who an­swer the phone can’t ad­dress their com­pli­ca­tion.

The cen­ter now sees about 10 pa­tients a day — about 3 per­cent of those Hop­kins treats for can­cer on an av­er­age day — and most go home af­ter a few hours.

“We knew send­ing our pa­tients to the emer­gency room was not in their best in­ter­ests,” said Sharon Krumm, di­rec­tor of nurs­ing ad­min­is­tra­tion at the Johns Hop­kins Kim­mel Can­cer Cen­ter. “If they have a heart prob­lem or a stroke, yes, it’s a good place for them, but that’s not what was hap­pen­ing.”

The ur­gent care cen­ter’s pa­tients don’t just get bet­ter, more ef­fi­cient care, Krumm said. A study re­leased this week sug­gests that avoid­ing hos­pi­tal­iza­tions is sig­nif­i­cantly low­er­ing costs for pa­tients and re­duc­ing the bur­den on the health care sys­tem.

Can­cer treat­ment con­trib­utes more to health care costs than any other dis­ease, ac­cord­ing to the study re­searchers from the Kim­mel Can­cer Cen­ter and the Hop­kins Bloomberg School of Pub­lic Health.

The av­er­age out-of-pocket costs as­so­ci­ated with a new can­cer di­ag­no­sis ranged from $2,116 for Med­i­caid ben­e­fi­cia­ries to $8,115 for those with Medi­care and no sup­ple­men­tal in­sur­ance, ac­cord­ing to the study of 18,000 pa­tients be­tween 2002 and 2012 pub­lished this month in JAMA On­col­ogy.

Hos­pi­tal­iza­tions ac­counted for up to 46 per­cent of the pa­tient’s bill. The study found that among a group of pa­tients at Hop­kins, the av­er­age num­ber hos­pi­tal­ized was cut in half af­ter the cen­ter opened.

The Hop­kins cen­ter is among a half­dozen around the coun­try that have opened for can­cer pa­tients, aiming to keep them out of the emer­gency room and hos­pi­tal beds, ac­cord­ing to Lind­say Con­way, man­ag­ing di­rec­tor of The Ad­vi­sory Board Co., which pro­vides re­search and con­sult­ing to hos­pi­tals.

2013 re­port the firm pro­vided to 1,200 hos­pi­tals found more than half of Medi­care pa­tients ac­tively get­ting chemo­ther­apy visit the emer­gency room each year, and close to two-thirds of those vis­its result in hos­pi­tal­iza­tions.

The most com­mon rea­son is pain, and the emer­gency room isn’t al­ways equipped to han­dle the prob­lem, the Ad­vi­sory Board re­port said. Doc­tors some­time or­dered un­needed tests and pro­ce­dures, and pa­tients were ex­posed to po­ten­tial in­fec­tions at a time when their im­mune sys­tems were com­pro­mised.

The re­port also found the av­er­age chemo­ther­apy-re­lated emer­gency visit cost about $800 and the av­er­age in­pa­tient stay av­er­aged $22,000.

A doc­tor out­side of Philadel­phia is be­lieved to have pi­o­neered the idea for can­cer ur­gent care about five or six years ago, said Con­way, who leads the Ad­vi­sory Board’s on­col­ogy roundtable pro­gram that rec­om­mends best prac­tices to hos­pi­tals.

The model al­lowed pa­tients to get care af­ter reg­u­lar busi­ness hours. Pa­tients could call first for ad­vice from trained physi­cian as­sis­tants or nurses on car­ing for them­selves at home in­stead of go­ing to the emer­gency room.

Con­way said these “triage” phone lines could be help­ful be­cause most hos­pi­tals and on­col­ogy prac­tices do not see enough can­cer pa­tients to jus­tify a sep­a­rate ur­gent care cen­ter. An al­ter­na­tive for hos­pi­tals are web­sites where pa­tients could get stan­dard­ized in­struc­tions on car­ing for com­mon side ef­fects and be able to mes­sage se­curely with clin­i­cians.

“Hav­ing a phys­i­cal space and a team of clin­i­cians ded­i­cated 24/7 to see­ing can­cer pa­tients is a sig­nif­i­cant in­vest­ment in re­sources, and only hos­pi­tals that see thou­sands of cases a year can pro­vide that,” Con­way said. “A lot only have 500 pa­tients, so they have to ex­plore other op­tions.”

The Univer­sity of Texas South­west­ern Med­i­cal Cen­ter is one of the large aca­demic hos­pi­tals that de­cided it could jus­tify an ur­gent care cen­ter.

Dr. Thomas Froehlich, med­i­cal di­rec­tor of the cen­ter’s can­cer clin­ics, be­gan of­fer­ing ur­gent care a few years ago af­ter find­ing pa­tients were call­ing af­ter hours and be­ing sent to the emer­gency room, where he said staff didn’t read­ily know how to treat the can­cer pa­tients’ mouth sores, fevers, nausea and de­hy­dra­tion.

Some­times, he said, a hos­pi­tal visit is nec­es­sary, for ex­am­ple, for blood clots that some­times de­velop af­ter some treat­ments. In those cases, ur­gent care staff can help pa­tients by­pass the emer­gency room and get ad­mit­ted to the hos­pi­tal.

Like Hop­kins, the Texas ur­gent care cen­ter is run by physi­cian as­sis­tants who over­see other spe­cially trained staff who man phone lines. They of­ten contact a


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