Kevin Brigle, PhD, ANP, describes an outreach program that provides rural communities with access to cancer treatment.
For the past 15 years, I have run the rural outreach program at Virginia Commonwealth University's (VCU's) Massey Cancer Center, a National Cancer Institute–designated center located in Richmond.
The program was established in the early 1990s, after providers at Massey observed high cancer mortality rates in the rural parts of the state. They took a closer look at the demographics and discovered a lack of cancer care in those areas. To help solve this problem, Massey partnered with four smaller, local hospitals on the outskirts of the city to set up specialized oncology clinics at those hospitals.
Nurses stationed at these hospitals received specialized chemotherapy education and training at VCU, then returned to their hospitals to run the daily operations of the clinic, while Massey providers traveled to the regional, rural clinics one day a week to see patients.
One long-term goal for the program was to establish cancer outreach sites that could potentially attract oncologists to practice in the rural community. In the beginning of the program, two physicians and a nurse practitioner traveled to a rural site once a week. Now, of those four original sites, two have oncologists present on a regular basis, one has an established oncologist present daily, and the rural hospital at the fourth site was bought by the Massey Center.
A Day in the Life of Cancer Care Nomads
On days when we travel to the clinic, our teams meet on the parking deck of Massey a little before 6 a.m. to discuss our plans for the day, then head out to our respective sites at one of the four rural hospitals. In the beginning, we were nomads. Providers were sent to one of the four clinics in the program when needed, but eventually, we assigned nurse practitioners and physicians to specific sites on specific days of the week.
By the time we arrive at our site, around 7 a.m., the three nurses who manage the clinic have already started checking in patients and taking labs. We need to open the clinic early because we are working in blue-collar areas: Our patients need to get in at 7 a.m. and get out the door by 8 a.m. so they don't miss an hour's pay. Typically, the person who is providing transportation for the patient needs to do that as well.
On an average day, we will see 20 patients at the clinic. My expertise is in hematologic malignancies, but we treat every cancer patient who walks through the clinic doors. Typically, our staff is able to treat many of those patients on site, saving them from having to travel to Massey or a larger hospital for advanced or specialized care.
We work closely with our nursing colleagues and, at the end of the day, we all sit down together, review the day's caseload, and discuss the care plan for each patient.
The Ins and Outs of Outreach
Before we opened this outreach program, traveling to the larger hospital in Richmond for care was a huge barrier for patients who lived in rural areas and did not have access to reliable transportation or who could not take the financial hit of missing work to travel to appointments. Now, we are able to provide them with care in their hometowns.
For our patients with leukemia, that means, for example, they can receive blood products on the same day that they present to the clinic, rather than having to drive up to the larger hospital to get labs and blood products.
These outreach sites also ease the treatment burden on our patients with, for example, multiple myeloma who are undergoing a hematopoietic cell transplantation. Usually, patients are required to stay within 30 minutes of the hospital; for patients and families living in more remote areas, that would require their staying in Richmond. Having an outreach clinic enables them to return home sooner after transplant.
Still, launching a rural outreach program like the one we have at Massey is a complicated process: It involved making local contacts, hospital administrators developing a contract, and providers getting credentialed at the smaller hospital. It also requires constant communication among all the involved parties. While there's no limit to good ideas, putting them into practice can be hard.
Overcoming Rural Roadblocks
Working in more remote, rural areas presents unique challenges, compared with working in a larger hospital setting.
For example, we do not have access to certain specialized services. We do not have a pulmonologist or surgical oncologist on staff at the outreach clinic, so we can't perform certain procedures, like CT-guided biopsies.
Our clinic is staffed with qualified advanced practice providers (APPs) – some of whom are able to practice independently, thanks to an April 2018 Virginia law allowing experienced APPs greater practice authority. However, while we can treat most of our patients on site in the clinic, if an individual requires more specialized care, they will have to travel to Massey or another nearby large hospital for treatment.
We recognize that this puts an additional financial strain on our patients, so we have instituted assistance programs to help pay for the travel costs, such as applying for grants so that we can purchase gas cards for clinical trial participants. There is now a radiation oncology facility near my clinic, but in the old days, we even used to run a van every day to bring patients from the outreach hospital to Massey for treatment.
Is a Rural Clinic Right for You?
In my experience, the health-care providers who practice in small towns are the people who grew up there, went away to get training, and came back. Attracting oncology specialists, and even primary care providers, to these areas is a major challenge; rural outreach programs are designed to fill that gap.
I grew up in a small town in northwest Ohio, so I have a fondness for rural areas and the people who live in them. But I understand that working in a rural area isn't everyone's first choice, largely because actually living in those areas is less alluring than settling down in a larger, more developed city.
The strongest argument I can make for working in a small, rural clinic is the relationships that you have the opportunity to form. We get to know our patients very well. Right now, we have an active panel of about 275 patients, and it's like a giant family. Our nursing colleagues can point to a name on the patient list and say, "That's my neighbor," or "That's Joe's cousin." It truly makes you feel like part of the community when a patient says, "I remember you – you treated my mother."