Abstract P1-03-10: The implementation of a patient referral service in a Brazilian cancer center
Authors: Makdissi FB , Costa Filho ER , Conti EC , Santos LC 
Published: May 2019

Abstract
BACKGROUND: Healthcare systems face problems of cost increases and poor delivery organization. Integrated delivery may reduce costs and improve quality and health outcomes.
OBJECTIVE: To describe how the A.C. Camargo Cancer Center, aiming at greater integration, implemented a referral service for breast cancer patients.
METHODS AND RESULTS: The process was divided in three phases: 1) AS IS ANALYSIS, 2) BENCHMARKING, 3) PILOT & IMPLEMENTATION.
1) AS IS ANALYSIS
A.C. Camargo was responsible for treating 16% of all breast cancer cases that arose from 2000 to 2012 in São Paulo State. Prior to implementation of the program, there was no special patient classification at the initial appointments.
2) BENCHMARKING
As proposed by MD Anderson Cancer Center, we used the patient's classification at the time of an appointment request (regular screenings, undiagnosed or breast cancer patient).
As proposed by Memorial Sloan Kettering Cancer Center, we used a "Physician Referral Service" staffed by "Referral Specialists" and "Trained Oncology Nurses" to collect patient information prior to the first appointment.
As suggested by Princess Margaret Cancer Center, we collected patient care data (e.g., abnormal imaging, palpable lump).
3) PILOT & IMPLEMENTATION
Phase I: Feb. 13, 2017 to Dec. 28, 2017. We reached 7% of new patients in the Breast Surgery Department (BSD): 48% were in the Cancer Group, 45% in the Abnormal Imaging Group (Undiagnosed) and 7% in the Palpable Lump Group.
New patients were classified by the Call Center. Electable cases were referred to the Nurse Navigator, who proceeded with appointments according to protocol.
Root cause analysis of non-captured patients led to the following improvements: extension of participant Call Center cells, script review, and implementation of a training program.
The Phase I results led to the following improvements: 1) reclassification of a subgroup with highly suspicious images as the "Cancer Group"; 2) Transfer of the new referral and scheduling functions to the Call Center; and 3) Implementation of new "first appointment items", personalized for each patient group. This information was displayed to the physician and operations staff in advance of the consultation.
Phase II: Dec. 29,2017 to June 28, 2018. We reached 100% of new patients in the BSD: 17% were in the Cancer Group, 23% in the Abnormal Imaging Group, 8% in the Palpable Lump Group, and 53% in the Regular Screening Group.
Phase II results led to the following improvement: 1.) Distribution of the cancer groups'first appointment items equally among surgeons.
Phase III: From June 29, 2018 to the operation. Implemented new appointment items for new clinical patients and for pre-treatment returns.
CONCLUSION: With implementation of the Referral Service, the BSD at A.C. Camargo is now able to identify the reason for each appointment before the first consultation. This practice promotes operational predictability and more effectively organizes the personalized journey of each patient, including care on the part of Nurse Navigators for the most critical cases.
REFERENCE: Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001
Citation Format: Makdissi FB, Costa Filho ER, Conti EC, Santos LC. The implementation of a patient referral service in a Brazilian cancer center [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-03-10.