The Importance of Teamwork in Oncology Care Transitions

Surabhi Dangi-Garimella, PhD

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 convened by The American Journal of Managed Care® for Patient-Centered Oncology Care®, held November 16-17, 2017, in Philadelphia, Pennsylvania.

Panelists included Rose Gerber, director of patient advocacy and education, Community Oncology Alliance; 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 serve as her inspiration for her current role as a patient advocate and educator. Having received her diagnosis while she was raising a young family, Gerber said that she and her husband were devastated. 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 dis- closure 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 includes a cardiologist because of heart conditions developed as an adverse effect of the trastuzumab, an endocrinologist, and a neurologist. Additionally, she struggles with weight issues, which could be related to some of the treatments that were administered. “But at the center of it 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 a 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 prescriptions, the pharmacist can keep track of when a patient was due for a clinic visit but may have missed the appointment and can be the point of contact for the patient. “So, a pharmacist can play a more proactive role in patient care,” McCullough said.

Diaz noted a very specific challenge at Florida Cancer Specialists: Consolidation has increased its size to over 100 sites across the state, with more than 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: The team that works with active patients has protocols in place so it knows 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 coordinates care with the doctors and calls the patients to ensure they are aware of upcoming appointments.

The team that manages transitional care coordination has access to software that allows a coordinator to follow all of the information and ensure patients are taken care of during their 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 regard to 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.

As a nurse navigator in her practice, Gilbert noted that she works closely with the pharmacist on patient education, especially with oral oncolytics, which is at the top of their plan. A 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.
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