Leading Change: Implementation of a New Care Coordination Model

Today’s healthcare environment is characterized by a multitude of changes: acquisitions and mergers, streamlining of operations, restructuring and leadership shifts, new regulatory requirements with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, implementation and meaningful use, and advances in technology driven by the employment of electronic health records. The impact of these changes is complex and fraught with challenges in an industry that historically and culturally is cautious and slow to change.

The oncology specialty is simultaneously witnessing significant advances in cancer treatments with the introduction of numerous immunotherapeutic and biologic agents as effective therapies for the most challenging diseases. Many of these treatments include oral agents, necessitating a shift in ambulatory care delivery models to ensure adherence and astute toxicity assessment, reporting, and management for patients outside the traditional chemotherapy infusion suite. With President Barack Obama’s recent proclamation of a “moonshot” to eradicate cancer, the cancer community is challenged by increasing numbers of pipeline and fast-tracked treatments as we effectively double down on the precision medicine initiative (The White House, Office of the Press Secretary, 2016). Although this is exciting progress, the pace and magnitude of managing the changes can often be overwhelming. Cancer care organizations are responding to shifting demands in care delivery by restructuring space and systems and acquiring new skills, while ensuring clinical efficiency and patient satisfaction with the overall experience.

Implementation of a New Model

City of Hope National Medical Center, a National Cancer Institute–designated comprehensive cancer center in Duarte, California, has implemented a care coordination model designed to provide patient- and family-centered care and to organize care through multispecialty disease management teams rather than treatment specialty clinics (Johnson, Giesie, Ireland, Rice, & Thomson, 2016). This new model of care incorporates the role of a nurse care coordinator (NCC) to provide support for high-risk, high-complexity patients across the care trajectory. Objectives of the NCC role are to improve patient access to necessary care, enhance the patient experience, and strengthen coordination throughout the care continuum. Success will be measured by reduced rates of admissions, readmissions, and hospital lengths of stay and increased patient satisfaction. Provider and nursing satisfaction also will be assessed as a measure of disease team effectiveness in strengthening patient and clinician interactions.

The new care model was implemented first in City of Hope’s new Women’s Center. This center offers clinical care and imaging services for breast, gynecology, plastic surgery, and clinical genetics practices. Although the physical space was a significant part of the change, implementation of the new care coordination model became the transformational change and required a team of committed leaders and clinicians. Existing roles were examined to determine key responsibilities and identify any gaps. The team used the RACI model to determine differences in responsibility, accountability, consulting, and informing between the new NCC role and existing roles of ambulatory care assistant, clinic nurse, nurse practitioner, and case manager. Johnson et al. (2016) detailed the role delineation, staffing model, curriculum for the NCC, and team process for outlining workflows in the care coordination model for the Solid Tumor Program.

Implementation Framework

Leading these changes required a structured approach and commitment across the organization. The Accelerating Implementation Methodology model was used as an implementation framework to ensure that the project met operational, technical, business, and human objectives. This model guided project planning, implementation, and monitoring and identified strategies to manage resistance, build agent capacity, generate sponsorship, and ensure readiness. Table 1 highlights key elements of the model with definitions and deliverables.

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The implementation team participated in a two-day change management retreat with significant emphasis paid to the critical role of project sponsorship. The four major roles for any change project are outlined in Figure 1. Completion of a key role map aided the development of a sponsorship cascade through each management level and across the organizational boundaries. The key role map completion process served to identify and include all possible stakeholders across departments. The sponsor is the individual who authorizes and demonstrates ownership for the change; he or she must possess sufficient organizational power and influence to initiate resource commitment (authorizing sponsor) or reinforce the change at the local level (reinforcing sponsor). Sponsorship for transformational change is an active condition of leaders who are expressing, modeling, and reinforcing their personal commitment to the transformation (IMA Worldwide, 2015). In a matrix environment, such as City of Hope, multiple sponsors often exist. The team had to address the complexity of the reporting relationships at the executive level to ensure alignment and the ultimate success of the project. Lines of authority and accountability were clarified to align medical, nursing, and operational leadership. This exercise during the second day of the change management retreat was a critical accomplishment for the team and the key component of a successful implementation.

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Conclusion

Change can be challenging but also exciting, particularly when the team envisions a new and spacious environment and the opportunity to work more collaboratively and deliver excellent and coordinated patient care. This complex project—a new space and a new care model—was successfully launched in early 2016 without disruption in clinic schedules. The structure that was used guided the leadership team to set the vision, engage staff in the process, logically plan and organize various stages, and keep all key members informed of progress, delays, and other issues. Even when an unexpected delay in opening the new space occurred secondary to a change in the state licensure process, the team was able to adjust and develop interim plans to temporarily continue patient care in the existing space. Operational and quality metrics are being collected to monitor outcomes related to the objectives of improving patient experience, access, and clinical efficiency, while providing a better working environment for the staff. Operational and performance metrics to be tracked and used to guide ongoing improvements in the provision of care consist of time to new patient appointment, clinic wait time, patient satisfaction, patient volume per day, number of no-shows, number of cancellations, percentage of patients for whom medication reconciliation is complete, and percentage of patients departing with after-visit summary. The next phase of the project will be to expand to include the remaining solid tumor services. Space and model redesign and relocation of clinics will require strong leadership based on the successful implementation model at the Women’s Center, a vision of a new future and an unwavering commitment to advance cancer care.

References

IMA Worldwide. (2015). AIM (Accelerating Implementation Methodology): A practical guide to change project management. Lakewood, CO: Author.

Johnson, S.A., Giesie, P.D., Ireland, A.M., Rice, R.D., & Thomson, B.K. (2016). On the scene: Developing a nurse care coordinator role at City of Hope. Nursing Administration Quarterly, 40, 39–50.

The White House, Office of the Press Secretary. (2016, February 1). FACT SHEET: Investing in the National Cancer Moonshot [Press release]. Retrieved from http://1.usa.gov/1WYb5Oe

About the Author(s)

Ireland is the clinical nursing director of the Solid Tumor Program at City of Hope National Medical Center in Duarte, CA. No financial relationships to disclose. Ireland can be reached at aireland@coh.org, with copy to editor at ONFEditor@ons.org.