Nurse and PA Launch an SMA for Breast Cancer Survivors

Shared medical appointments (SMAs) are an innovative way to create appointment access and improve patient care. Cleveland Clinic’s SMA program began more than a decade ago. The healthcare system now has SMAs for patients in more than 20 areas of focus, ranging from chronic heart failure to skin conditions. Recently, Cleveland Clinic launched SMAs for breast cancer survivors at two locations, Cleveland Clinic’s Lyndhurst Campus and Fairview Hospital.

At Fairview Hospital, the breast cancer survivor SMA is held one Wednesday a month from 4:30 to 6 p.m. It’s led by Mary Longdon, MS, PA-C, and Jean Ellsworth-Wolk, MS, RN, AOCNS, coordinator of the cancer survivorship program at the Cleveland Clinic Cancer Center at Fairview Hospital. Four to eight women attend the SMAs, where they have short, individual clinical examinations then meet as a group to discuss common survivorship issues and receive education. At the Lyndhurst Campus, the breast cancer SMA is held every other week on Wednesdays from 5:30 to 7:30 p.m. for a total of seven visits. (The Lyndhurst Campus also offers a prostate cancer SMA for prostate cancer patients and survivors.)

Catering to breast cancer survivors

Jean Ellsworth-Wolk, MS, RN, AOCNS

Part of the impetus for starting a breast cancer survivor SMA was in response to mandatory standards related to survivorship. In 2012, the Commission on Cancer of the American College of Surgeons released its patient-centered Survivorship Care Planning standard to be phased in by 2019. More recently, the National Accreditation Program for Breast Centers (NAPBC) issued a set of standards in 2014 that include breast cancer survivorship care.

“Having shared medical appointments is just one idea for addressing the long-term care and education needs of this particular group of patients,” says Ellsworth-Wolk. “Their needs are very similar.” She and Longdon began offering the shared appointments last fall and have since tweaked them to best serve the needs of the group.

As the medical provider, Longdon meets with each patient privately, taking vital signs, checking medications and performing breast exams. Then all the women gather in a group where they share any questions and hear about some aspect of survivorship from Ellsworth-Wolk, who has taught a cancer survivorship class for six years. The topics she covers include:

• The risk of lymphedema
• Sexuality
• Fear of recurrence
• Weight and exercise
• Bone health

“There’s a lot more education that takes place in this type of environment,” says Ellsworth-Wolk. “When a patient comes in for a private appointment, they don’t get an hour of education.” In addition, the women share ideas and learn from one another. “I am amazed at the emotional support they give one another,” she says. “They understand they are not alone.”

Tips for starting an SMA

Mary Longdon, MS, PA-C

“SMAs vary significantly from one patient population to another,” says Longdon. “For instance, if you have a diabetes clinic, you don’t necessarily have to take patients out of the room. But because we’re doing breast exams, we have to include a private setting.” Longdon and Ellsworth-Wolk met many times with their team as they planned for the unique requirements of an SMA for breast cancer survivors. The team includes two experienced nurses dedicated to breast health, Patricia Huddleston, RN, and Paula Keating, RN, as well as administrative assistant Dana Stachowski. The team shares these tips for successfully launching an SMA:

• Attend an SMA as an observer. Before starting their shared appointment program Ellsworth-Wolk sat in on an SMA for bariatric surgery patients and Longdon attended one focused on women’s health. They considered what components would and wouldn’t work for their patients.
• Talk to clinicians who head SMAs. Ask nurses, physician assistants and physicians who run SMAs to share their experiences and advice.
• Seek out organizational support. Cleveland Clinic has an SMA department that offers guidance and support.
• Hold a focus group. Longdon and Ellsworth-Wolk met with 10 breast cancer survivors to gauge their interest in an SMA and gain ideas. Participants completed a questionnaire at the end that asked them to evaluate their feelings about shared appointments and the subjects covered. Responses helped shape programming. For example, education on the fear of recurrence was added. “I had no idea that fear was so strong seven or eight years out,” admits Ellsworth-Wolk. “So we added that educational component, and it’s been well received.”
• Pick your team carefully. “This is a shared medical appointment for patients, but it’s very much a team approach in terms of caregivers,” says Longdon. She and Ellsworth-Wolk run the SMAs alongside Huddleston and Keating. Longdon says the RNs are “just amazing at handling the flow of the appointments and addressing patient needs and issues.”

The breast cancer survivor SMA at Cleveland Clinic is in its infancy, but shows great promise. “It’s been a great way to circle back with patients and review everything we’ve gone over during their treatment, but now focus on moving forward,” Longdon explains.

Perhaps more noteworthy is praise from patients, including these two comments: “It was more relaxed than a single appointment,” and “The shared appointment allows more time for discussion, which is good.”