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Evidence-Based Oncology June 2017
The Transition to Integrate Palliation in Cancer Care
Joseph Alvarnas, MD
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Amy Byer Shainman
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Rufus Collea, MD; Linda Pulver, RN, BA; Claire Ralli, LCSW; and Amanda Burgess, RN, OCN
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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
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Produced by Laura Joszt

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
Pharmacists play an integral role in enhancing transitions of care in patients undergoing cancer treatment through medication reconciliation, education, and post-discharge follow-up to ensure optimal, safe, and effective medication use.
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 
  • Increase patients’ access to discharge medications
  • Increase patient convenience, by avoiding a retail pharmacy visit post discharge for medication pick-up
  • Enhance medication adherence.
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:
  • Einstein Healthcare Network (Philadelphia, Pennsylvania)
  • Froedtert Hospital (Milwaukee, Wisconsin)
  • Hennepin County Medical Center (Minneapolis, Minnesota)
  • Johns Hopkins Medicine (Baltimore, Maryland)
  • Mission Hospitals (Asheville, North Carolina)
  • Sharp HealthCare (San Diego, California)
  • University of Pittsburgh School of Pharmacy and University of Pittsburgh Medical Center (Pittsburgh, Pennsylvania)
  • University of Utah Hospitals and Clinics (Salt Lake City, Utah).
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.

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