The Importance of Teamwork in Oncology Care Transitions

Patient care is a team effort, and this is truly evident in oncology care. A panel on the importance of clinical and non-clinical stakeholders in a patient’s care trajectory brought together a diverse group of stakeholders at The American Journal of Managed Care^®’s Patient-Centered Oncology Care^® meeting, held in Philadelphia, Pennsylvania, November 16 to 17, 2017.

Panelists included Rose Gerber, director of patient advocacy and education, Community Oncology Alliance (COA); Stacey McCullough, PharmD, senior vice president for pharmacy, Tennessee Oncology; Michael Diaz, MD, director of patient advocacy, Florida Cancer Specialists & Research Institute; and Rebekah Gilbert, RN, BSN, OCN, nurse practitioner, Hematology Oncology Associates of Central New York.

Gerber, a breast cancer survivor, narrated her personal experience as a patient and a survivor, which has served as her inspiration for her current role as a patient advocate and educator. Diagnosed while she was raising a young family, Gerber said that she and her husband were devastated when she was first diagnosed. Overwhelmed by the news, and vulnerable, Gerber and her husband were ready for her to participate in any clinical trial that was offered. “However, when I looked at the pages and pages of consent forms and disclosure forms, I was scared,” she said, adding that she values the importance of clinical trials as an option for patients and firmly believes that patients should be engaged to participate in trials.

Gerber also noted that care transitions are extremely important for patients. “I never thought, 14 years later, that I’d still be actively seeing my oncologist, as I continue dealing with some of my health issues,” she said, explaining that her chemotherapy (trastuzumab) and other cancer treatments increased her susceptibility to secondary health issues. So, in addition to an oncologist, a radiologist, and a surgeon, Gerber's care plan has included a cardiologist because of heart conditions developed as a side effect of the trastuzumab, an endocrinologist, and a neurologist. Additionally, she was struggling with weight issues, which could have been related to some of the treatments that were administered. “But at the center of it all all has been my oncologist,” Gerber said.

Gilbert said that each care team in her practice includes a patient navigator, a nurse, an advanced practitioner, and a doctor. “We huddle each morning to discuss our patients who will be visiting our clinic that day, as well as the patients who have been identified as being high-risk.” This keeps everyone on the team abreast of what’s going on with their patients. Additionally, the clinic has a telephone triage system, with 3 dedicated nurses on call all day, who either bring in the patient or give them home-care instructions over the phone. “Very rarely do we send a patient to the ER [emergency room],” Gilbert said.

McCullough explained that, following the advent of oral oncolytics, Tennessee Oncology established an in-house retail system that operates as a specialty pharmacy. “Our healthcare system has, so far, underutilized pharmacists, but a pharmacist can definitely step in and be a part or a better partner along with nurses and physicians,” she said. Pharmacists have access to the electronic health record as well as the doctor’s notes. Also, when they access the system to refill prescription needs, the pharmacist can keep track of when a patient was due for a clinic visit but may have missed the appointment, and they can be the point of contact for the patient. “So, a pharmacist can play a more proactive role in patient care,” McCullough pointed out.

Diaz noted a very specific challenge that they face at Florida Cancer Specialists. With consolidation, they have grown to over 100 sites in the state of Florida, with over 200 oncologists on the team in addition to advanced practitioners. “Each site had their own model on how they operated, and we needed a process so everyone would work in a similar fashion to be able to provide all the advanced care that patients need,” Diaz explained. Their 40 care coordinators have been divided into 3 teams:

• Care coordination for patients on active treatment
• Care coordination for survivorship care
• Transitional care coordination

The team that works with active patients has protocols in place so they know how often they need to contact the patients. They also have specific questions when they reach out to these patients, in addition to routine clinic visits.

The team dedicated to survivorship care coordinates with the doctors and also calls the patients to ensure they are aware of upcoming appointments.

The team that manages transitional care coordination has access to software that allows the coordinator to follow all the information, ensure they are taken care of during the transition out of a hospital, in case they need extra care post discharge, because they may or may not always know whether they need to get in touch with a doctor with regards a specific concern. “So, the bulk of the care we are trying to provide to our patients is handled by our care coordinators,” he said.

Gilbert noted that, as a nurse navigator in her practice, she works closely with the pharmacist on patient education, especially with oral oncolytics, which is at the top of their plan. The nurse also makes follow-up phone calls with the patient at pre-determined intervals, and if there are any issues, the nurse will let the team know to follow up with the patient.

“While the patient should be at the center, I think the oncologist, the nurse, the pharmacist, and even family caregivers should be part of the patient’s care team,” Gerber said, aptly summarizing the discussion.