Transitions of Care in Patients With Cancer

Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS

Introduction
While on the one hand healthcare is constantly evolving with new technology, medical advances, policy changes, and reimbursement strategies, on the other hand, the cost of avoidable readmissions or preventable adverse events (AEs) are burdening the healthcare system. Jencks and colleagues concluded that about 20% of Medicare patients were readmitted within 30 days, with about 50% of the 20% who were readmitted having no follow-up post discharge.1 In 2013, the cost of 500,000 readmissions was $7 billion, and the most common disease states contributing to this cost were acute myocardial infarction (AMI), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and pneumonia (PNA).2

Several factors, including older age, polypharmacy, comorbidities, functional impairment, and the lack of ideally structured transitions of care (TOC) programs to provide safe and effective care, may increase risk of readmissions and influence post discharge AEs.3 In efforts to reduce cost of readmissions, the Affordable Care Act introduced the Hospital Readmissions Reduction Program in 2010. This program allowed for decreases in Medicare reimbursement for acute care hospitals, except cancer and critical access hospitals, that did not meet targets for hospital readmissions within 30 days. The program focused on high-volume disease states that accounted for a large percentage of readmissions such as AMI, CHF, COPD, PNA, and vascular procedures.4

According to the National Cancer Institute (NCI), the cost of cancer care was estimated to be $125 billion in 2010 and could increase to $156 billion in 2020.5 NCI estimates that the number of new cancer cases in the United States will increase to 22 million within the next 20 years, with about 1.7 million patients newly diagnosed in 2017.5,6 However, survivorship of cancer patients has increased due to new advances in treatment.6 Over the last 15 years, the use of oral chemotherapy has nearly doubled7; still, the availability of these agents has, in part, transferred the responsibility of proper storage and administration to the patient, leading to difficulties with adherence and safety.8-10

Administration of antineoplastic medications in the inpatient and outpatient settings is complex, with variations in length of doses within a cycle. In addition to the cancer treatment, patients may receive antimicrobials to prevent infections; granulocyte-colony stimulating factors (G-CSFs) to prevent neutropenia; and other medications to help prevent and/or treat nausea, pain, diarrhea, constipation, and/or thromboembolism. Additionally, patients are living longer and inherently have more chronic comorbidities that necessitate medications taken concurrently with the cancer treatment. This scenario is a prime setup for potential errors for patients managing these medications at home.

Although cancer institutions are exempt from the current measures, it is likely that in the future, these institutions will be held accountable for readmissions and other major patient outcomes, as acute care hospitals currently are. Cancer centers need to adopt TOC processes that coordinate care for both complex cancer treatment and the patients’ associated comorbidities to ensure optimal care for this high-risk patient population.

Transitions of Care Models
Currently, no consensus exists on a gold-standard TOC program, but some essential components include medication reconciliation, structured discharge communication and facilitation, patient education, and timely post discharge follow-up. There are overlapping TOC challenges for patients, providers, and the healthcare system (Figure).

Medication Reconciliation
The Joint Commission has recognized medication reconciliation as a national patient safety goal to enhance continuity of care in medication management.11 Obtaining an accurate medication history is often challenging in the inpatient setting, and multiple sources of information are often needed to achieve this goal. Pharmacy technicians and pharmacy learners (eg, residents and students) can assist pharmacists in obtaining information from the patient, caretakers, medication lists within the electronic health record (EHR), outside pharmacies, and/or outpatient provider offices.12 Key components of a medication history are listed in Table 1.13 Any other medication-related information that may assist the inpatient team in making the best decisions for the patient’s current treatment plan should also be collected. After obtaining a complete medication history, a pharmacist should reconcile this information with inpatient medications to identify any discrepancies or omissions. The pharmacist will then discuss this information with the care team and facilitate making appropriate changes to active inpatient orders. This practice has been shown to prevent medication errors and reduce AEs.12

Medication Education and Postdischarge Follow-Up
Patients’ understanding of medication changes made during their hospitalization, and of their discharge medication regimens, may be hampered by complex treatment, limited health literacy, and/or language barriers.14 To overcome these barriers, appropriate medication education and structured discharge communication must be provided to clearly articulate both treatment and overall discharge instructions. Cancer care team members, including nurses and pharmacists, can help educate patients about their medications by using teach-back method to confirm understanding.15 Pharmacists can be particularly helpful in targeting patients being discharged on new high-risk medications and/or those patients whose new medication regimen has undergone many changes compared with their prior-to-admission home medications. Initiating the education process as soon as the discharge regimen is confirmed is important because of the significant information burden that the patient faces on the day of discharge. Chemotherapy calendars and medication sheets, including a medication schedule, are helpful tools to help patients recall detailed instructions. Some institutions have implemented bedside discharge medication delivery to:16,17  It is essential to have postdischarge communication, via face-to-face appointments or phone follow-up, to ensure a safe transition from hospital to home.18,19 Dickinson and colleagues conducted a systematic review of studies using various technologies such as telephone, clinical decision support, automated voice response symptom reporting, or smartphone applications to follow up with patients after initial cancer treatment.18 Based on the results, investigators concluded that these technology-based interventions did not compromise patient satisfaction or safety when they measured symptoms, health-related quality of life, or psychological distress.

Transitions of Care Initiatives
Although cancer centers around the country have been providing TOC services for several decades through pharmacists, nurses, and/ or physicians,20 they have not formally implemented TOC programs as quickly as other acute care centers. One reason for this is that a universal approach would not work for cancer centers, because the transitional care needs of these patients vary depending on the type of cancer. For example, adaptations in chemotherapy calendars, supportive care medications, and drug monitoring will be much different for a patient who has pancreatic cancer versus a patient who underwent a stem cell transplantation. However, to address the needs of the dynamic healthcare landscape, cancer centers are adapting principles of TOC similar to those at acute care institutions.

Pharmacists, as members of the healthcare team, play a major role in improving health outcomes, quality, and safety.21 Expanding their role in TOC programs has the potential for a large economic impact as it relates to the pharmacists’ ability to decrease preventable AEs and subsequent readmissions. The Care Transitions trial provided needed resources and a nurse “transition coach” to patients older than 65 years of age after discharge and saw a decline in readmissions.22 Institutions have developed a variety of models that include pharmacists, pharmacy technicians, nurses, and providers, as well as combinations of any of the aforementioned healthcare team members. Table 2 describes the potential role of TOC pharmacy members.

Several other TOC programs have been described in the literature. Project RED (Reengineered Hospital Discharge Program) utilized nurses to help reconcile medications, educate, and coordinate outpatient appointments while clinical pharmacists called patients 2 to 4 days post discharge.23 In this study, which took place at an academic medical center located in an urban area, investigators found a lower hospital readmission rate for patients with these comprehensive interventions. Project BOOST (Better Outcomes by Optimizing Safe Transitions) implemented comprehensive TOC programs at 6 hospitals in Illinois.24 The implementation of physician mentors, who provided training and guidance to physicians, in Project BOOST demonstrated a reduction in hospital admissions by intervening with specific high-risk patients and facilitating communication and coordination between outpatient providers and patients.

In 2013, the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) collaboratively published the ASHP-APhA Medication Management in Care Transitions Best Practices. This guidance was published after reviewing more than 80 institutions’ TOC programs, and served to highlight 8 TOC models that best demonstrate the integration of pharmacists in care transition teams.25

They chose the programs based on the impact of the model on patient care, pharmacists’ involvement in the transition process from hospital to home settings, and how adaptable the program was perceived to be in terms of implementation by other health systems. The 8 programs were implemented at25: In addition to the best practices above, numerous studies show positive impact on patient outcomes when pharmacists are key participants in various TOC models.16,26-28

While there is a demonstrated need for pharmacist involvement in these services, institutions are often expected to provide these services in a resource-neutral fashion. Challenges arise when departments of pharmacy are faced with a need to deploy more of their staff to gather medication histories, educate patients, and complete post discharge follow-up while maintaining all existing operational and clinical services. One academic medical center approached this problem by taking an inventory of all responsibilities of current staff (order verification, clinical service provision, triage of calls to the pharmacy, missing medications, etc) and reallocating responsibilities. This resulted in a decrease in order-verification responsibilities for a number of pharmacists, allowing them more time to interact directly with patients without compromising overall workflow and safety from an order verification standpoint. Since these pharmacists were now spending more time directly on the units, they were able to take on additional responsibilities in triaging requests of nursing staff and providers, which allowed for an increase in order-verification responsibilities for some pharmacists due to assistance with those tasks.29

Meanwhile, development of formal oncology-specific TOC programs are underway. For their oncology patients admitted to the palliative medicine and solid tumor oncology inpatient services, the Cleveland Clinic implemented a TOC program with the following components:30
  1. Provider education
  2. Post discharge nursing phone calls within 48 hours
  3. Post discharge provider follow-up appointments within 5 business days.
Nurses provided symptom management, education, medication review, and a follow-up appointment reminder. The overall program helped reduce readmissions by 4.5% and provided $1.04 million in annual cost savings.30 With support from the ASHP Pharmacy Practice Advancement Initiative grant, the University of Texas at MD Anderson Cancer Center (UT MDACC) started a TOC pilot program to include medication reconciliation, education, discharge medication deliveries, and a 72-hour postdischarge phone follow-up.31,32 The team, consisting of pharmacy trainees, inpatient pharmacists, outpatient pharmacists, and clinical pharmacists, collaborates closely with internal medicine inpatient providers and coordinates care with outpatient providers to ensure safe and effective patient care. The outcomes for the TOC pilot, which is currently ongoing, are 30-day readmissions and adherence rate.

Even though the data have not been analyzed, it is evident that this program will have a positive impact on safe and effective patient care delivery. Many medication-related AEs have been prevented or caught during medication reconciliation, discharge education, and phone follow-up. For example, the TOC team caught the absence of numerous critical medications that had been accidentally omitted from patients’ inpatient medication list, such as antiarrhythmics, pain medications, antidepressants, and antihypertensives. The TOC pharmacists have also recommended discontinuation of high-alert medications that were deemed inappropriate to restart in the hospital due to the patient’s condition, such as anticoagulants in a patient with a concern for a bleed. Another example is that upon phone follow-up, TOC pharmacists were able to help reschedule a missed outpatient antibiotic infusion appointment, which likely prevented a readmission.

Some challenges for the TOC program include limited resources and time constraints, as the pharmacists must fulfill their daily responsibilities in addition to TOC activities. There are scheduling challenges with staff pharmacists, which limits continuity of TOC activities when multiple staff pharmacists cover a unit throughout the week. In addition, there is rapid turnover of TOC team members, mostly pharmacy students who are doing their rotations for a finite period. This turnover increases the workload on TOC pharmacists to continuously train new TOC team members to perform medication history and reconciliation. Utilization of pharmacy technicians or pharmacy interns would be a potential solution.

To overcome some of the challenges mentioned above, UT MDACC is implementing a new pharmacy practice model in addition to the TOC program; it will have integrated clinical pharmacists (ICPs) with operational and clinical responsibilities, such as order verification, triaging nursing/provider questions, anticoagulation monitoring, renal monitoring, and TOC activities. The goal for these ICPs is to provide consistent continuity of care on the patient unit that they are following.

Overall, current research, such as the Care Transitions trial, Project RED, Project BOOST, and ASHP-APhA Medication Management in Care Transitions Best Practices, suggests that having a comprehensive TOC program is more effective in lowering readmissions than is targeting individual components.22-25 The pharmacist should play an active role on an interdisciplinary team to provide safe and effective care to patients.

Models of Cancer Care Delivery
Cancer treatments are administered in a variety of settings, ranging from a small private practice to a large academic comprehensive cancer treatment center. Clinical outcomes may differ for certain disease states based on setting; for example, patients with a rare hematologic malignancy, multiple myeloma, who were treated at a high-volume center were found to have higher overall survival to those treated in community settings.33 The volume-outcome relationship is well known for surgical management of solid cancers.34 Some patients may not have access to a high-volume cancer treatment center given their geographical location, insurance network, or financial feasibility. Co-management is a potential solution, in which the patient receives treatment recommendations from a higher-volume center but visits a local physician to have the treatment plan implemented.33 Whether cancer care is delivered in a small community hospital or a large academic medical center, a multidisciplinary team that includes a hematologist/oncologist, surgical oncologist, radiologist, palliative care providers, midlevel providers, pharmacists, social workers, case managers, and spiritual care providers is essential to meet patients’ needs.35,36

Of the total 69 NCI-designated cancer centers, 47 are comprehensive cancer centers that perform laboratory, clinical, behavioral, and population-based research. Fifteen of the 69 cancer centers perform basic, population sciences, and clinical research.37 Many additional academic medical centers are not NCI-designated. Regardless of the shortfalls of respective models, cancer treatment teams need to identify the shortfalls of their models and adapt their approach to account for the diversity in practice settings where cancer care is delivered, although it may be challenging to coordinate the various fragmented services to ensure provision of comprehensive care. A primary cancer treatment team should be established to ensure care coordination, with the pharmacists involved in all pharmacotherapy aspects throughout the patient’s transitions within the healthcare system.

Cancer Treatment Challenges
Antineoplastic medications can be administered in the outpatient or inpatient setting depending on the type of regimen, insurance coverage, and center where the drug is being administered. Starting cancer treatment requires careful coordination with the patient’s insurance carrier to obtain pre-approval for high-cost antineoplastic medications, and G-CSF if clinically indicated. Additionally, care teams can help patients enroll in patient financial assistance programs to help cover high-cost medications.38 Some chemotherapy regimens that require an infusion pump, such as continuous-infusion fluorouracil, may require working with outside infusion companies; patient education must also be provided. Furthermore, long commutes to clinics for patients undergoing cancer treatment can be strenuous on patients and caregivers. Coordinating patients’ schedules to combine appointments can minimize trips and decrease the patient’s stress.

Cancer treatments range from simple once-a-day oral medications to multiple inpatient and outpatient infusion treatments with variations in “on” and “off” periods, further complicating the administration of cancer care. Regimens of such medications as hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone require an initial inpatient infusions followed by outpatient infusions.39 Patients need to be informed of complex drug dosing frequencies such as weeks off treatment, as with regorafenib or dexamethasone pulses to prevent overdoses.39,40 Certain supportive-care medications like azole antifungals may need to be taken around the time of each chemotherapy session to prevent drug interactions, which adds to the complexity of the treatment.

Managing Care Transitions During Cancer Treatment
Managing complications of cancer treatment may require hospital admission and holding treatment. EHRs need to have the capability to put treatment plans on hold to prevent the administration of chemotherapy and biotherapy during the period when toxicities are being managed. Patients may need to continue intravenous antibiotics in the outpatient setting, requiring careful coordination with the case manager to set up home infusion services. Some large institutions have the ability to administer intravenous antibiotics, intravenous fluids, blood products, or G-CSF in the outpatient setting through an infusion center. In addition to medications, patients may have other needs such as setting up home oxygen, outpatient physical/occupational therapy, medical equipment, and home health services. Certain infusional chemotherapies, such as continuous infusion doxorubicin, require central line access; in such cases, patients must be provided with line care supplies and trained to care for their own lines.

Depending on the chemotherapy regimen, patients may need to have laboratory blood monitoring in the outpatient setting, in time patterns ranging from once a cycle to several times a week. Communication is essential when multiple physicians are involved in the management of a patient. Fortunately, EHRs are making those transitions easier. However, providers must still communicate among one another about a co-managed patient’s cycles of chemotherapy, laboratory values, and changes in condition between cycles. These communications can be meaningfully achieved through physical or electronic letters sent to the co-managing physician. Sample orders including chemotherapy and biotherapy as well as supportive care medications may be provided for physicians taking over care for subsequent cycles. Pharmacists at large cancer centers with experience with the regimens can collaborate with smaller centers to ensure optimal delivery of the regimens. Patients may need to go to skilled nursing, long-term acute care, rehabilitation, or hospice facilities. It is important for care teams to provide clear medication, laboratory, and monitoring support to these facilities, as they may not be accustomed to monitoring these types of patients.

Conclusions
Cancer care is complex and requires an interdisciplinary approach with careful coordination of many specialties. While cancer treatment providers and supportive professionals have been providing these services, they are adapting care delivery to enhance quality and reduce cost, based on incentives provided by health plans. TOC models are being evaluated to enhance the transitions of patients undergoing cancer care. Coordination by the primary treatment team and thorough medication reconciliation and education provided by pharmacists, in conjunction with appropriate follow-up, is essential to ensure optimal outcomes and minimize AEs.
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