Nurse Practitioners Improving Follow-Up Care for Patients at the Cleveland Clinic

TON May 2016 Vol 9 No 3 - Cancer Center Profile

Bridgett Harr, CPN, works at the Cleveland Clinic Foundation in the radiation oncology department. The Cleveland Clinic is one of America’s top 5 hospitals, according to U.S. News & World Report’s “2015-16 Best Hospitals.” Located in Ohio, the Cleveland Clinic is also a top-ranking cancer center, providing a wide range of services and expertise to get patients with cancer the treatment and support they need. The Oncology Nurse-APN/PA spoke with Ms Harr, an adult advanced nurse practitioner, about her work at the Cleveland Clinic, and award-winning study about clinic-based acute rehabilitation for patients led by advanced practice nurses (APNs).

What is your role at the Cleveland Clinic Foundation?
Bridgett Harr (BH):
I work as a nurse practitioner in the radiation oncology department. Mainly, I care for patients with head and neck cancer (HNC), but I also follow patients with skin cancer as well. My job is to provide care to patients from consult through follow-up after active treatment is complete, although I am most active with patient care during follow-up.

A fellow nurse practitioner from medical oncology and I run a survivorship clinic for HNC patients who are ≥6 months from definitive treatment and without evidence of active disease. This clinic is integrated into our normal follow-up routine, and provides patients with a treatment summary/survivorship care plan that addresses treatment received, and what to expect in the future.

What are the challenges of your job?
BH:
Every cancer patient’s experience is different. Sometimes, the cancer diagnosis is [his or her] first real experience with the healthcare field, and it can be difficult to manage not feeling in control of the diagnosis and trajectory. Regardless of medical history, however, everyone has some experience, whether personal or through family, of cancer and/or the healthcare system. The challenge comes in recognizing and validating/acknowledging each patient’s unique needs and fears so we can make this experience with treatment the best and easiest it can be. This builds an important rapport with patients and their families.

What is rewarding about your job?
BH:
Chemoradiation for HNC is not an easy treatment to get through. One of the best parts of my job is seeing a patient who was at his or her lowest during treatment walk back in for follow-up a couple months later doing great, almost back to normal life.

What are you excited about in the field of HNC right now?
BH:
There is still so much we don’t know about HNC. In the past couple of years, we have begun to recognize the importance of the human papillomavirus as a prognostic marker in this disease. We still don’t know, however, why this virus transforms to cancer in some and not others. As a result of this virus and the fact patients are living longer after definitive treatment, there are current research trials looking at the possibility of de-escalation of treatment (ie, lower doses of radiation and/or chemotherapy). In theory, this would decrease both acute and late side effects of treatment.

Patients with HNC are noteworthy for having severe side effects related to treatment. You presented an award-winning poster at ASTRO [American Society for Radiation Oncology] about management of posttreatment HNC. Tell us about your study.
BH:
My abstract was centered around the establishment of an APN follow-up clinic for HNC patients immediately following (chemo) radiation to 3 months posttreatment. During this period, acute side effects of treatment are healing, and symptom management/support is needed. Two groups of patients were studied: those followed in routine follow-up (once at 4-6 weeks posttreatment, and again at 3 months posttreatment), and those followed in the APN clinic (seen at 2-3 weeks posttreatment, and again every 2 weeks until symptoms stabilize).

Outcomes of emergency department visits and/or hospital admissions were documented for each patient, and used as the end point for this study. If a patient had either an emergency department visit or hospital admission, we considered him or her positive for an adverse event. Patients in the APN clinic were seen twice as often as those seen in routine follow-up. Although there was no difference seen in patients who received chemoradiation—probably because of the intensive follow-up provided by medical oncology, as well—there was a significant decrease in adverse events between those who were followed in the APN clinic versus those seen in routine follow-up (60% in the standard follow-up group vs 16.7% in the APN follow-up group; P = .010).

This study highlights the important benefits APNs can provide to this patient group. We have a unique ability to follow these patients intensively to manage symptoms in an outpatient setting, which reduces costs for both the patient and hospital system as a whole, and also increases patient satisfaction.

What was your career path? What led you to become an oncology nurse advanced practitioner?
BH:
I was a registered nurse for 5 years prior to becoming a nurse practitioner on a general oncology floor caring for patients with leukemia, lymphoma, and other solid tumors. I knew I wanted to become a more active team member in the care of oncology patients, and, for this reason, I went back to get my masters/certification to become an adult nurse practitioner. I’ve now been a nurse practitioner for 3.5 years in radiation oncology. In oncology, I always feel that I am making the biggest difference.

What advice would you give to a person trying to become an oncology nurse?
BH:
It takes a while to learn how to put things into perspective. In my specialty, this may be the first time a patient experiences the healthcare system. We are telling them they need chemotherapy and radiation, and, basically, that they are going to lose their appetite, taste, and energy. They probably won’t work after a couple weeks of treatment. Basically, patients are putting their lives on hold—and their families and friends for that matter; there is little control left over this. As expected, some patients take a while to adjust, and sometimes need to vent or get out fears that they don’t want to share with loved ones. Understanding this, and letting them talk, cry, yell, and scream is sometimes the most important thing you can do. You need to understand why they are behaving this way, take a step backward so as not to react, and just let them vent. This can be difficult.

What would you do if you won the lottery? Would you change what you are doing?
BH:
If I won the lottery, I would definitely travel more. However, I don’t think I would stop working. I truly love what I do, and really think I would miss it. There are so many opportunities in this field to do good and help others with serious health challenges.

Last modified: May 24, 2016