1. 16th Reach to Recovery International Breast Cancer Support Conference A pilot program of the implementation of Cancer Case Manager (breast) in Hong Kong in 2010 Vanessa Chun Advanced Practice Nurse Department of Surgery Kwong Wah Hospital Hong Kong 11 November, 2011

2. Background  Breast cancer is the commonest female cancer in Hong Kong.  Multidisciplinary team approach can ascertain quality care and better results.  The emphasis is on patient and her journey of breast cancer treatment.

3. Objectives  To streamline clinical pathway and logistical issues  To coordinate across specialties and enhance the communication within multidisciplinary team  To address patient needs for education, psychosocial support and access to resources  To act as patient advocacy and single-point contact between patient and clinicians  To coordinate and monitor treatment progress and follow up appointments  To identify potential gaps in service

4. Expected outcomes  Patient empowerment (to facilitate informed decision on treatment)  Patients experienced improved outcomes (improve and standardize the quality of care – protocol driven)  To maintain optimism while fighting breast cancer  To enhance patient satisfaction with care (establish the nurse-client rapport)  Enhanced quality of life (early discharge, early return to society)  Cost saving (decrease the length of hospitalization)

5. Methodology  Before the commencement of the program, a standard clinical cancer care module for breast cancer is developed.  Supporting IT program is designed for operational convenience and data capture.

6. Role of case manager combine into pathway of breast cancer patient New case of breast cancer (D1-10) Breaking bad news (D10-14) Operation (W6-8) Post-op rehab (Post-op D7-21) Post-op Pathology disclosure (Post-op D20-27) 1st oncology consultation (Post-op D30-37) 1st surgical FU appt (Post-op W26-34) 1st oncology FU appt (Post-op W26-34) Neo-adjuvant chemotherapy MDT meeting

7. Newly diagnosis stage  To initiate protocol  To check and arrange  early baseline investigation (MMG)  collateral meeting (breaking bad news)  multidisciplinary team meeting (case discussion)  To inform related professional team members Patient Journey Break Bad News 1st Imaging 1st Treatment Other Treatment / FU Diagnosis Cancer Case Manager Notify

8. Role of case manager (newly diagnosis stage)  To trace all the appointments and investigation reports  To arrange further investigation if needed: CT scan, MRI scan, PET scan, biopsy  To facilitate decision making and to prepare patient for operation  To control the time for operation

9. Patient education & counseling  To facilitate patient knowing her professional team  To help the patient to known herself  To advocate on behalf of patient  To provide relevance written information  To offer social support and introduce the patient support group (Yin Chun Club)  To refer to other professional team for assessment if indicated (medical social worker, clinical psychologist)

10. Clinical photos

11. Written information An outcome management flow chart Relevant information is given according to different stages

12. Contact nurse and number SOS!!! Where can I get help?

13. Discharge planning where and how can I get help after discharge ?

14. Role of case manager (early post-operative stage)  To enhance early recovery and wound healing of patient  To educate patient on wound care and shoulder mobilization exercise according to patient ’ s condition  To refer to physiotherapist for difficult case  To provide psychological support and encourage self care  To trace the pathology report and arrange the post-op collateral case conference for pathology disclosure  To facilitate patient to understand and can make decision on her adjuvant therapy  To introduce the concept, side-effects of different adjuvant therapy  To arrange oncology consultation appointment if needed

15. Role of case manager (rehabilitation stage)  To follow patient’s coping ability and extended problems  To provide bra and prosthesis fitting if needed  To arrange and confirm the appointment of surgical and oncology  To trace and monitor the progress of oncological management plan of patient  To check patient ’ s experience on adjuvant therapy  To check problems patient encountered is under professional care  To educate patient on long term risk care

16. Role of case manager (extended care at home)  Problems encountered by patient at home  To arrange follow up in nurse clinic by appointment booking  Consultation  Counselling  Lymphoedema management  Nipple areolar tattoo  Post 5 years breast cancer patients health screening clinic

17. Role of case manager for the patient on neo-adjuvant treatment (patient with advanced condition, detours from the normal pathway)  To check the progress of the neo-adjuvant treatment  To arrange patient and her relatives to attend collateral case conference for the discussion of surgical intervention  To facilitate decision making (BCT vs mastectomy +/- reconstruction)  To prepare patient for operation  To control the time and put on list for operation  To arrange nurse clinic FU after operation according to the protocol

18. Data collection and documentation (1)

19. Data collection and documentation (2)

20. Data collection and documentation (3)

21. Result and outcome (1)  1 April 2010 to 31 December 2010  239 patients (newly diagnosed breast cancer) Age56.9 (mean) 29 – 97 (range) Education level: No formal education Primary education Secondary education Tertiary education 3.3% 27.8% 63.3% 5.6% Total family income (monthly) Less than $10,000 $10,001 - $20,000 $20,001 - $30,000 $30,001 - $40,000 Above $40,000 42.2% 32.2% 13.3% 5.6% 2.2%

22. Result and outcome (2) Total number of treatment interventions 246 Number of multidisciplinary team meeting:  X-ray meeting: 87  Combined Breast Clinic: 26 113 Number of nurse clinic attendances:  Counselling  Pre-op education  Post-op rehabilitation  Wound / drain care  Post adjuvant treatment management  Phone counselling  Others: prosthesis fitting, lymphoedema management, nipple areolar tattoo etc. 1015

23. Result and outcome (3) Treatment interventions

24. Result and outcome (4) The nature of nurse clinic attendances

25. Result and outcome (5) Patient Journey 1 st +ve Biopsy Date Date of Treatment Decision (Final) 1 st Definitive Treatment Date Average # of days Days from 1st +ve Bx to 1st definitive treatment 12.425.938.3 Remarks: Only cases that followed the above pathway were included in the particular field of the above analyses (Milestones in Care Pathway)

26. Result and outcome (6)  Patient Satisfaction Questionnaire (PSQ) Explanation provided by nurse: Very satisfied44.4% Satisfied48.9% OK4.4% Service provided by nurse: Very satisfied45.6% Satisfied46.7% OK6.7%

27. Service improvement Shorten the waiting time for investigation, operation,... Streamline the clinical pathway Multidisciplinary team meeting for every cases Update knowledge

28. Acknowledgement  Medical team  Dr. C M Chan  Dr. W L Ying  Dr. S W Sun  Dr. C Y Lui  Dr. L K Chan  Dr. C Kwok  IT team  Mr H Lee  Nursing team  Ms Amy Or  Ms M W Tsui  Ms W M Cheung  Ms N S Wong  Clerk  Ms Y L Leung