ACCC National Oncology Conference: 2022 Coverage

Ochsner Health’s Chemotherapy Care Companion Reduces Hospital Visits, Drives Patient Satisfaction

Ochsner Health’s remote monitoring system for patients receiving cancer treatments helped drive down hospital stays and emergency department (ED) visits by one-third while improving patient satisfaction among those who used the service, according to a physician who led the project.

Zoe Larned, MD, system chair of hematology and oncology for Ochsner, outlined the development of the system, called Chemotherapy Care Companion, and shared early results during a session of the Association of Community Cancer Centers (ACCC) 39th National Oncology Conference held in West Palm Beach, Florida. Ochsner’s program was among the recipients of the 2022 ACCC Innovator Awards, given to projects that improve patient care and are cost-effective and replicable.¹

In January 2020, creating a digital health system to monitor patients with cancer between office visits was a natural next step for the Ochsner Cancer Institute, which had already embedded urgent care slots within its oncology clinics starting in 2018, Larned explained. Little did Ochsner know how vital remote monitoring would become, when the COVID-19 pandemic gave added value to the ability to remotely track patients’ blood pressure, temperature, pulse, and weight, as well as responses to questions about symptoms.

“The rationale for doing more with monitoring processes in cancer care is that [this is] a health care delivery method that uses technology to allow us to monitor patients outside of the clinical setting and between visits,” Larned said.

This is especially important in cancer care, she explained. Although advances in systemic cancer therapies offer substantial benefits, they can also come with significant toxicity. The ability to use technology to record patient metrics and symptoms remotely means “we’re able to continue to monitor them in ways that we have not historically been able to do before.”

Larned said that 27% of patients with solid tumors have a least 1 visit to the ED during their treatment course; patients with hematologic malignancies often start treatment in the hospital.

Ochsner’s system is designed to flag signs of the top reasons for admission or an ED visit: infection and sepsis, dehydration, pain, and hypertension.

The system, launched at Ochsner Cancer Institute in New Orleans, Louisiana, called for patients to enroll through a smartphone or iPad app, where they provided consent and information, and for the health system to provide them with a blood pressure cuff, ear thermometer, and digital scale. Patients were asked to record their metrics and answer questions twice a day, in the early morning and midafternoon, which would give care teams time to see which patients were showing signs of dehydration or infection or were reporting adverse effects (AEs) from medication. If a patient needed an urgent care visit, those slots were already built into the schedule.

Larned’s presentation included screenshots of what the enrollment process looks like on an electronic health record and how seamlessly it fits into the workflow. Patients newly prescribed chemotherapy were automatically enrolled, and Ochsner has since added in those patients already receiving therapy for cancer. And despite the name, those taking oral therapies or immunotherapy are also included—and may stay enrolled after their regimen ends due to the nature of AEs.

Results. Preliminary data collected from January 2020 through December 2021 showed that patients who participated in the digital monitoring program had a 33% reduction in ED visits and hospital admissions compared with those who were not enrolled.

As of today, Larned said, 500 patients have enrolled in the program, ranging in age from 23 to 86 years. Adherence to the program is 70%; Ochsner considers a patient adherent if they complete at least half of the assigned daily tasks.

Although 50% of the patients enrolled have stage IV cancer, Larned said the program has monitored patients at every stage—and she is optimistic about its usefulness in patients with earlier-stage cancers. “We know if we can monitor patients between appointments, it’s just as important to get our [patients at] earlier stages enrolled,” she said.

Patient surveys show high enthusiasm for the program, and Larned said patient feedback has been valuable in making improvements. Ninety percent said they were very satisfied or satisfied, and 90% would recommend the program to a friend or family member, she said.

Since its launch, Chemotherapy Care Companion has expanded to Ochsner’s other regional cancer centers and clinic sites, which stretch from northern Louisiana in Shreveport to the Mississippi Gulf Coast. Ochsner leaders have refined the system to shut off if a patient is admitted to the hospital and have adapted the baseline measures to acknowledge that Louisiana’s overall health status is poor compared with other states. (Separately, Ochsner is leading a statewide effort to raise Louisiana’s health measures by 2030.)
Chemotherapy Care Companion is not considered optional at this point, Larned explained. “We’ve made this a value-based metric for our team. All providers have bought in as part of our value-based measures.” 

Reference
1. 2022 winners. Association of Community Cancer Centers. Accessed November 2, 2022. https://www.accc-cancer.org/home/about/awards/accc-innovator-awards/2022-winners


Delaware’s ChristianaCare Embeds PCP Care Within the Cancer Center

With patients who have cancer living longer, it’s more important than ever to build connections between the oncologist and the primary care provider (PCP) who will take care of a patient’s health needs beyond cancer.

But what happens if the patient with cancer has no PCP? This was the challenge that ChristianaCare’s Helen F. Graham Cancer Center and Research Institute, based in Newark, Delaware, took on when it embedded PCP care within the cancer center, both to provide for the immediate needs of the center’s patients and to connect them with primary care for the future.

ChristianaCare is the dominant health care system in Delaware, the nation’s second-smallest state, with 3 hospitals including a Level 1 trauma center.¹

But, as Debra Delaney, MSN, FNP-BC, primary care nurse practitioner, explained during the Association of Community Cancer Centers (ACCC) 39th National Oncology Conference, held in West Palm Beach, Florida, Delaware’s smallness can still mean long drives for some residents in the most rural stretches of the state. ChristianaCare’s program was among the winners of the 2022 ACCC Innovator Awards.²

Delaware’s shortage of PCPs is acute, meaning that ChristianaCare was seeing more and more patients with cancer who had no family practice to rely on outside of cancer treatment. An estimated 15% of the cancer center’s gynecological oncology patients had no PCP, for example. That meant they had no other physician to help manage comorbidities or deal with care coordination, which led to treatment delays and unnecessary stress.

When the idea was presented to Delaney to embed PCP care at the cancer center, she knew it made perfect sense. “Everyone should have a [PCP], but we know that’s not the case,” she said.

The launch of PCP care in the cancer center took flight in January 2021, with a small unit of 5 beds, advanced practice clinicians, a registered nurse, and a medical office assistant. Delaney also sees some patients via telehealth.

Within 6 months, there were 70 patients, she said.

In a year’s time, ChristianaCare has learned a lot. “It’s a constantly evolving practice,” Delaney explained. The original plan was to set up a referral to primary care as soon as treatment ended, but the cancer center soon found that more challenging than expected. Patients might end up going to the emergency department if they don’t have a PCP; if a suspicious mass is found or a new issue arises, they are referred back. Patients who need presurgical evaluations and have no PCP are also referred.

And there are advantages to being embedded in the cancer center, Delaney said. Access to each patient’s cancer care records is a huge advantage, as she can see all the notes; she described how being part of the cancer center offered access to information that prevented her from prescribing a diarrhea medication that would have interfered with a patient’s clinical trial. In another case, the oncologist had explained which medications were contraindicated with cancer therapies, including one that was not obvious.

Still, it’s part of Delaney’s job to ultimately connect patients with local PCPs when possible, and she spoke of those successes, too. She manages the timing of the handoff back to a local provider and helps patients find one when possible. “If you’ve got patients [who] travel over 2 hours from downstate…they prefer to have a primary care provider that [is] closer to their home, which I can certainly help with,” she said.

When these handoffs occur, Delaney ensures that the new provider has all the patient’s data and fully understands the case.

And there are a few patients who resist a transfer, even when it’s in their interest. Delaney reviewed the case of a veteran who found the Veterans Affairs Health Care System very complex, but the cancer center worked with him on a transition so he could access a host of social supports for which he was eligible.

“I sat down with him, and we had a long talk about this,” she said. When the veteran was able to make the transition, “he was very grateful.”

Oral oncolytic delivery. Baptist Health South Florida’s Miami Cancer Institute had a problem. The rise of oral oncolytics in cancer care, staffing challenges, COVID-19, and processes that clinicians used to manage prior approval challenges had all combined to create barriers to patient medication education.

An audit had revealed a major gap: Miami Cancer Institute offered high-quality education, but it wasn’t always timely. With problems such as white bagging increasing, only about 60% of patients received a prescription and an education session in the same visit. That meant there was a risk that some would start taking oral oncolytics before their education session.
Morgan Nestingen, MSN, APRN, AGCNS-BC, NEA-BC, OCN, ONN-CG, director of nursing for Patient Intake and Navigation Services, explained both the commitment and the process that led to same-day education, which earned Miami Cancer Institute a 2022 ACCC Innovator Award.²
Nestingen admitted that some were skeptical that the goal of same-day education delivery could be achieved. Prior authorization had bedeviled physicians—and it was driving prescribing practices, she said.

The plan involved creation of a dashboard that would measure compliance by capturing orders on the electronic health record and following through to ensure that navigators and nurses had the opportunity to complete all necessary steps to educate patients on the medication they would be taking while they were on site. Innovative technology allowed for electronic consent, and on-call nursing support is part of the equation. It took plenty of 7 am Friday meetings, support from information technology staff, and “a lot of microadjustments” to make minor changes that added up to a big shift, Nestingen said.
By the second month of the project, same-day compliance had reached 90%; by the end of month 3, it had reached 95%. The project is now heading into a second phase, she said. The lesson, Nestingen emphasized, is that “technology can enhance traditional approaches to in-person care coordination.” 

References
1. About ChristianaCare. ChristianaCare. Accessed November 2, 2022. https://christianacare.org/about/whoweare/
2. ACCC announces 2022 Innovator Award winners. News release. Association of Community Cancer Centers. October 13, 2022. Accessed November 2, 2022. https://www.accc-cancer.org/home/news-media/news-releases/news-template/2022/10/13/accc-announces-2022-innovator-award-winners


Allina Health: Bringing Population Health Strategies to Oncology

Three years ago, Allina Health, a not-for-profit health system that operates 10 hospitals and more than 90 clinics in Minnesota and western Wisconsin, decided to invest in cancer care with a population health focus. Doing so required Allina to “remap the patient experience” in cancer care, according to Mike Koroscik, MBA, MHA, vice president of oncology at Allina Health Cancer Institute (AHCI).

Koroscik offered an update on how that process has evolved for AHCI, which launched in October 2021.¹ Koroscik presented “Preparing for Population Health in Oncology” during the Association of Community Cancer Centers 39th National Oncology Conference, which was held in West Palm Beach, Florida.

His talk added to the emerging consensus that improving patient experience and bringing down cancer costs calls for prevention through healthier living or catching cancer early when it is easier and less expensive to treat. The second approach requires using data and risk stratification strategies to screen patients and to rethink reimbursement, which would have to reward health systems based on a population health model rather than paying for testing based only on individual patient risk.

Koroscik began by discussing why population health in oncology “is in vogue.” Although Allina made its commitment before the pandemic, COVID-19 highlighted the enormous need for a population health approach, and the “silver linings” of that experience are fueling some of AHCI’s early steps.

“Cancer care was disjointed,” Koroscik said. “Even mapping our largest cancer type—breast cancer—had over 33 touch points” before the AHCI overhaul began. Clearly, an intervention that revamped the traditional hub-and-spoke relationship between flagship and rural sites had to be rebuilt.
“We knew our value proposition was redefining cancer care, making it accessible,” he said. “We had to focus on a new network.”

In August 2020, Allina Health reached an agreement on what was described as a “landmark” value-based contract with Blue Cross and Blue Shield of Minnesota,² and Koroscik said larger payers are the focus of AHCI’s efforts in value-based care.

From there, he said the AHCI model would be one of accessible “seamless connections” that recognizes the multiple factors—mind, body, and spirit—that affect overall health. The model includes the following components:

• Integration of primary care and mental health
• A patient financial navigation program that addresses financial toxicity
• Exceeding expectations on screening and surveillance
• Convenient hours and availability of urgent care, to reduce emergency department (ED) visits and hospital admissions
• Better utilization of nurse navigators, “to thrive, not just survive” under bundled payment arrangements
• Upfront engagement of payers in innovative population health initiatives, which include social and community-based initiatives

Lessons from COVID-19. The sharp drop in cancer screening that took place in the early months of the pandemic—and the resulting cancers that followed—build the case for an emphasis on preventive care and addressing social needs. “The numbers were devastating,” Koroscik said.

But building a patient-centered, population health–focused oncology model necessarily “depends on finding a sustainable path forward,” Koroscik said, so cost control is part of the picture. At the macro level, that means building a model centered on providing evidence-based care, minimizing care variation, and paying attention to the total cost of care. Other interventions will focus on the following:

• Reducing acute care crises
• Ensuring fewer ED visits and hospital admissions, and reducing
  length of stay
• Improving care transitions and care management
• Selecting the appropriate site of care, including home care where appropriate

Typical characteristics of value-based care agreements are benchmarks based on the total cost of care, shared savings, and pay-for-performance metrics. Adding population health to oncology care will put more focus on risk adjustment, Koroscik said. Palliative care will continue to gain attention, as will minimizing unnecessary variation in care.

To support these agreements, Allina Health will rely on informatics support that goes beyond traditional pathways toward more real-time assessment and better panel management. Koroscik reviewed the elements that go into a composite risk score, which is a metric and decision tool that reflects the urgency of the patient’s situation, the depth of clinical need, financial risk, social determinants of health, and likelihood of adherence.

“For us, this is a real game changer,” he said. This is where Allina Health can change incentives for physicians to align with quality targets, reduce variation, and improve outcomes.

Current areas of focus are ED avoidance, clinical pathways (medical, radiation, and surgical), shifting symptom management near the infusion center, the home hospital program, lung cancer screening, and encouraging serious illness conversations. Looking ahead, Koroscik is mindful of what is coming from the CMS in alternative payment models (APMs), including the long-delayed Radiation Oncology Model that will likely reduce payments. Gathering data now is essential to be ready for when the APM arrives, he said.

Allina Health is trying new things: 18,000 patients have been screened as part of a social vulnerability pilot, and Koroscik said there are programs for lesbian, gay, bisexual, transgender, and queer populations and for Minnesota’s Somali community.

In Allina’s work with payers, he said, it’s important to keep in mind that “bundles might be good, or they might not be good,” depending on the population.

What’s critical is data. Even getting a basic measure such as how many patients have accessed the ED at 30 days isn’t always simple.

“Only 10 years ago I was data starved,” Koroscik said. “I don’t have too much data, but it’s getting the right data.” 

References
1. Allina Health announces launch of comprehensive cancer institute. News release. Allina Health. October 19, 2021. Accessed November 2, 2022. https://www.allinahealth.org/about-us/newsroom/2021/allina-health-announces-launch-of-comprehensive-cancer-institute
2. Allina Health and Blue Cross and Blue Shield of Minnesota commit to landmark value-based contract in Minnesota. News release. Blue Cross and Blue Shield of Minnesota. August 27, 2020. Accessed November 2, 2022. https://www.bluecrossmn.com/about-us/newsroom/news-releases/allina-health-and-blue-cross-and-blue-shield-minnesota-commit


City of Hope: Adapting Pharmacy Roles With an Eye Toward Retention

The “great resignation” has hit institutions large and small, and even one of the nation’s leading cancer research and treatment centers is not immune.
So, when City of Hope National Medical Center, centered in Duarte, California, found itself struggling to attract and retain clinical pharmacists, a rethinking of their role was in order, according to Wafa Samara, PharmD, chief pharmacy officer, City of Hope Pharmacy Enterprise, and Sepideh Shayani, PharmD, BCOP, executive director of pharmacy enterprise, City of Hope Pharmacy Enterprise.

Samara and Shayani offered an overview of how City of Hope tackled its pharmacy retention challenge during the Association of Community Cancer Centers 39th National Oncology Conference, which was held in West Palm Beach, Florida. Several sessions that day focused on staffing issues, which attendees identified as a top problem during a session held the day prior.

Samara introduced the audience to City of Hope’s 100-year-old history and mission; the health system, now expanded beyond its southern California base, is a National Cancer Institute–designated Comprehensive Cancer Center and part of the National Comprehensive Cancer Network. It attracts top talent to be sure—its scientists have pioneered advances in stem cell transplants and chimeric antigen receptor T-cell therapy.

But as Shayani noted, all that requires the work of 250 oncology clinical pharmacists, and “they are a rare breed.”

“What we have been seeing over [the] past several years is a trend of highly trained pharmacists making a decision to choose alternate career paths—not always in patient care,” Shayani added.

City of Hope, she said, “recognized a need for us to optimize our patient care model” to allow pharmacists to work at the top of their license and, where possible, to engage in clinical activities—work that keeps pharmacists engaged and retains them.

This would require an overhaul of the pharmacy department structure, which Shayani described as “a beautiful challenge for us.”

City of Hope hires both clinical pharmacists and pharmacy technicians; the former can work in clinical activities or in operations, which involves administrative work and making medicines. The titles of most of these staff did not truly reflect the scope of their duties, she said.

In addition, City of Hope looked to research by the University of North Carolina on oncology pharmacists in academic medical centers1; 44% of the respondents had been in their roles for at least 5 years, and 21% had been in their jobs for 10 years. The research found that 60% of these staff were open to alternative careers, and 23% were at high risk for attrition, meaning they were actively looking for a different job.

Notably, the survey found that clinical work increased job satisfaction and made pharmacists less likely to leave—a result consistent with what City of Hope had observed.

So, how could City of Hope respond? Samara outlined a road map for change, recognizing that “changing culture and care models is not a one-time event.”

Step 1 was a gap analysis, which looked at how other organizations managed their oncology pharmacists.

Step 2 created a new career ladder with more distinct job descriptions and responsibilities; those who wanted to remain in operational titles could do so, but those who wanted to focus on clinical activities could move into newly created titles.

Step 3 involved communicating the restructuring plan to all stakeholders and getting the resources to make it work. This also involved creating pathways for internal staff to shift jobs. Some new hires would be needed.
Step 4 will implement the restructuring plan, and this “will go on for a long time,” Samara said.

Many elements are needed for restructuring to work, Shayani said. Besides creating new titles for the staff, City of Hope redeployed the numbers in ambulatory and inpatient areas and used technology to streamline operations so that inpatient pharmacists could be with patients.

Collaborative practice agreements, which are permitted by California’s licensing board, allow pharmacists to prescribe medications and manage patients under certain conditions. This has opened the door for pharmacists to manage clinics and run point on a host of items, from oversight of medication toxicity to management of oral therapies to dose adjustments and billing where appropriate. Pharmacists have taken on a medical oncology head and neck clinic and a multiple myeloma clinic, for example.
Working to the top of their license has allowed pharmacists to take on tasks such as handling transitions of care in an allogenic stem cell transplant clinic and has provided opportunities to take greater roles in clinical research, including presentations at conferences. It has also created opportunities for flexibility for work-from-home scheduling, Shayani said, which has helped City of Hope meet the needs of parents with young children.

Finally, Samara said, the process has also allowed City of Hope to examine how it can improve the diversity of its workforce. “We did not match the community we serve,” she said. An internship program that brought in students from underrepresented communities—on salary and with housing support—has just graduated its first cohort, she said; the hope is that these students will become future applicants for the residency program.

Samara said there are many lessons from the experience: “For us, we are successful because we got leadership buy-in.” That meant the process received support throughout from the information technology staff and other resources.

But staff engagement and culture change remain the biggest challenge. City of Hope held town hall meetings so that pharmacists would understand, “What’s in it for me?” And leadership must accept that some pharmacists will still leave, while others will stay.

“This is a journey, and we need to [be] nimble,” Samara said. “We need to be ready to change and tweak as we go.” 

Reference
Rao KV, Gulbis AM, Mahmoudjafari Z. Assessment of attrition and retention factors in the oncology pharmacy workforce: results of the oncology pharmacy workforce survey. J Am Coll Clin Pharm. Published online August 11, 2022. doi:10.1002/jac5.1693