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A Regional Radiation Oncology Network Is Developed to Meet Community NeedsAndrew Salner, MD, Hartford Hospital Abstract Introduction Needs Identified Tertiary Care Partner Selected NRRON Formed Program Development Radiation oncology services are an essential treatment component in a multidisciplinary system of care for cancer patients. Because of inadequate access to radiation services in northeastern Connecticut, however, it was determined that many cancer patients in that area were not getting the most comprehensive care. Based on the results of a needs assessment, the region's community hospitals, which have historically been competitors, partnered to develop a regional radiation oncology plan. A tertiary care center was selected to complete the system and deliver technical and professional radiation oncology services. This resulted in the formation of a four-hospital, not-for-profit joint venture committed to delivering radiation oncology services to a heretofore underserved area. [Managed Care & Cancer 1(1):10-13, 1999] IntroductionIn the early 1980s, it became apparent that cancer patients in northeastern Connecticut had comparatively less access to radiation oncology services than those living in other areas of the state. Accordingly, concern was expressed in the community that the level of care in the region was suboptimal. To obtain radiation oncology services, it was often necessary for patients to travel relatively long distances. This problem was compounded by the fact that motor vehicle travel in the region can be difficult due to a lack of adequate highway service to many of the more rural towns. This creates a significant obstacle for elderly patients as they are often debilitated and lack transportation. Further, they may be reluctant to burden family members or friends for transportation. This was felt to influence the selection of treatment regimens that did vs those that did not include radiotherapy. A qualitative study performed by the cancer registries in this region indicated that the use of lumpectomy and radiotherapy in the primary management of breast carcinoma decreases as one moves east, away from the sophisticated radiation oncology services available in Hartford. In many situations, patients were effectively deprived of treatment options that were felt to be best for their care. Preliminary analysis showed that only a third of patients in more rural areas received radiotherapy as part of their care as compared with the 50% to 60% that is usually noted in the literature. By the late 1980s, the three community hospitals serving this region recognized an increasing need for radiation oncology services in their area. In the late 1980s, Johnson Memorial Hospital partnered with a tertiary care hospital and filed a certificate of need (CON) with the Commission on Hospitals and Health Care for developing a radiation oncology facility. Manchester Memorial Hospital and Rockville General Hospital partnered with a different tertiary hospital to develop a competing CON for radiation oncology services in the southern portion of the service area. By 1991, when regional disparities in health care became evident, the state regulatory agency directed the three community hospitals to perform a regional needs assessment and develop a program that would appropriately meet the requirements of underserved areas. Needs IdentifiedBy early 1992, Johnson Memorial, Manchester Memorial, and Rockville General began to explore the feasibility of developing a single radiation oncology program for the communities served by the three hospitals. The ensuing collaboration of these former competitors clearly benefited the institutions and communities they serve. As part of a comprehensive needs assessment and planning process, the three-hospital task force contracted with a nationally known planning and consulting company to help develop the regional system. Several important conclusions resulted from these studies: Access to radiotherapy service was indeed limited for this region of Connecticut, and a need for this project to provide such services within the communities east of the Connecticut River clearly existed. Travel times for patients varied upwards of 1.5 hours or more, roads were sometimes limited by single lanes with significant traffic, and patients expressed concerns about accessing inner-city hospitals for reasons of safety, security, and traffic in the inner city. Much of the need for radiotherapy services in this region was established based on communications to the planning group from physicians (both specialty and primary care), and patients and their families. Cancer affects most circles of friends, families, and groups of colleagues. Many such groups were affected within the region, and their communications to the planning group regarding the need for radiation oncology services were forwarded by family members, friends, and community organizations to the community hospitals. These unsolicited letters, particularly those that gave examples of suboptimal care being delivered because of lack of access, were indeed the catalyst that led to establishing these services. Review of cancer patient volume and projected volume of radiotherapy patients indicated the need for two linear accelerators. Considering the problems posed by restricted highway access and the geography of the region, it was decided that two sites were required; one to serve the northern area and one to serve the southern area. These would exist under the umbrella of a single regional program. A tertiary care facility with a proven track record in providing comprehensive radiation oncology services at a separate site should be recruited as a partner to provide both professional and technical services. Models should be developed that place treatment equipment in community sites while maintaining support equipment and personnel at the tertiary site to be used as needed, thereby reducing duplication. Some patient visits to the tertiary site would occasionally be necessary, but the majority of patients could receive treatment at the community sites. Tertiary Care Partner SelectedThe need to partner with a tertiary care institution was based on several factors. For one thing, the community hospitals had no prior experience with delivering radiation oncology services. Starting such a service and recruiting appropriate medical and technical staffs was not considered feasible, particularly given the shortage of specialists needed in this area. Further, low-volume community hospitals could not support the kind of equipment and staffing present in tertiary centers. Installing linear accelerators with multiple energies (both photon and electron), simulators, brachytherapy programs, 3-D planning computer systems, and staffing with physicians, physicists, dosimetrists, engineers, and technologists is beyond the support capabilities of smaller, community hospitals. Partnering with a tertiary care hospital offers access to all these services while providing the majority of actual daily treatments within the community setting. Also, quality improvement, access to new technologies, maintaining state-of-the-art care, and providing facilities to support appropriate staff and equipment are more easily accomplished in a larger system. A request for proposal was developed by the three hospitals and their consultant to find a tertiary care partner. Several institutions responded to this request and gave presentations to the joint hospital task force of community physicians and oncologists, administrators, and consultants. Ultimately, Hartford Hospital was selected as the tertiary partner, because (1) it is the largest provider of comprehen-sive radiation oncology service in the region, (2) it is a Varian Associates Center of Excellence for northeast United States, (3) it has experience in establishing two comprehensive satellite facilities, (4) it has a rich depth of staff, including physicians, physicists, dosimetrists, and therapists, and (5) it initiated and maintains an excellent school for radiotherapy technology. An open staff model in which radiation oncologists from different institutions could practice in the new centers was considered. After much discussion with other such facilities around the country, however, it was concluded that this model posed several potential risks, including lack of singular leadership, lack of accountability for quality assurance and quality control, possible unhealthy competition at each site, and lack of identifiable uniform protocols. It was decided, therefore, that Hartford Hospital was to provide both technical and professional tertiary service as well as medical leadership. NRRON FormedThe four-hospital partnership formed the not-for-profit 501C3 company called the Northeast Regional Radiation Oncology Network, Inc. (NRRON), and assembled the appropriate letters of support from the public, patients, families, medical staff, community agencies, and civic organizations. A detailed CON was developed exploring access issues for patients and families and the need for two sites east of the Connecticut River. The NRRON site-selection group, made up of one administrator from each hospital (the administrator from Hartford Hospital is also Chief Medical Physicist) and the medical director of NRRON (also the medical director of radiation/oncology at Hartford Hospital) met weekly. A hospital location was not considered essential, as the majority of patients would be ambulatory. Potential sites would have to be (1) cost effective, (2) accessible to the largest population of patients, (3) patient-focused, and (4) near other medical facilities such as laboratories, radiology and medical oncology offices, medical office buildings, and community health agencies. The northern site selected is located in Enfield, a major population center. The facility, a new cancer center building erected on the campus of the ambulatory medical center for Johnson Memorial, houses ambulatory surgery, medical office buildings, medical oncology, and community physicians, and is easily accessible from several major highways. The selection of the southern site was more difficult. Initial locations farther east were rejected due to the prohibitive real estate costs in this burgeoning area. Ultimately, a site on the Manchester Memorial campus was selected because of its accessibility, cost effectiveness, and accessibility to inpatients, physicians' offices, medical oncology services, laboratories, and other medical services. A CON was completed and submitted to the Connecticut Office of Health Care Access in May of 1995. This ultimately culminated in a public hearing before the State Regulatory Agency in September 1996. On January 17, 1996, Connecticut's Office of Health Care Access approved NRRON's CON for a regional radiation oncology program in northeast Connecticut. State officials lauded the four hospitals for working together to develop a single regional program to meet the needs of citizens through service at two locations. State officials also praised the four hospitals for working together collaboratively in an unprecedented way and keeping the needs of patients and communities first and foremost. Program DevelopmentDetailed program and facility development was undertaken by NRRON and its architects. Collaborative efforts involved community medical oncologists and other stakeholders (hospital boards, medical staff organizations, and administrations). A new freestanding facility would be built for the northern site. The 10,500 square foot building would include approximately 6,500 square feet of space for radiation oncology, 2,500 for medical oncology, and 1,500 for patient support services. At the southern site, an existing space was chosen that would require renovation and modernization as well as the addition of the shielded linear accelerator cell on an adjacent piece of property. The hospital board at Manchester Memorial chose this space, in part, because of decreasing length of stay. Therefore, underused space was available. Each of the two locations were designed specifically with an eye toward convenient parking and ease of access for patients and their families. Construction on the two sites began in October 1997. The northern site was completed in October 1998, and the southern site is scheduled to be completed in January 1999. Rather than NRRON participating in capital costs of construction, the sites were constructed by the host hospital, and appropriate lease arrangements were made with NRRON. The NRRON partners developed the following model for program delivery: Based on the concept of community cancer centers, with NRRON occupying part of the space and community oncology in the other part of the space at each of two sites
This model allowed for equity contributions from each hospital to initiate service with relatively modest investment. Depending upon the financial success of the sites (including treatment revenues and fund raising), additional capitalization might allow the development of other facilities in the future, depending on patient and community needs. In conclusion, a regional radiation oncology network delivering cancer services based on community need was developed collaboratively by four hospitals that had previously been in competition with one another. This service was developed to en-hance patient acceess, cost effectiveness, patient focus, and high quality standards. Patients treated at the community sites will have access to radiation oncology services in their own community along with access to high technology services at the central site. This program offers a level of quality and technology comparable to that associated with tertiary based radiation oncology programs, which was an important objective of the working group. A thorough analysis of patient needs and demography has resulted in the establishment of sites that offer maximum access for patients, the services of nearby oncologists, laboratory and radiology services, community based agencies, and other medical services frequently used by cancer patients and families. © 2000 by PRR, Inc. All rights reserved. |
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