1. Eastman, Peggy

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The Association of Community Cancer Centers (ACCC) held its 37th National Oncology Conference virtually to highlight excellence in community cancer care. The meeting focused on the need for clinical trials at the community level. It also spotlighted provider wellness and featured a number of innovative programs that enhance the quality of patient care while improving the efficiency and cost-effectiveness of cancer care delivery.

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Care During COVID-19

In a session on engaging community physicians in clinical trials, 2020-2021 ACCC President Randall A. Oyer, MD, outlined a number of issues that should be considered. As previously reported in Oncology Times, Oyer's presidential theme is Community Oncology Can Close the Gap in Cancer Research. He is Medical Director of Oncology at Penn Medicine Lancaster General Health.


Oyer said he is pleased that a number of community practices have signed up to participate in the ASCO Survey on COVID-19 in Oncology Registry, which collects baseline and longitudinal data on COVID-19's impact on cancer patients with the goal of improving patient care. He also said ACCC and ASCO are collaborating on a joint initiative to improve the participation of minorities in clinical trials, noting that the steering committee of this project should be ready to report on its progress by the end of this year or early next year. Oyer believes clinical trial care "is better care," and if adequate resources are provided, "I think it is a physician satisfier."


Oyer said clinical trials can answer questions about COVID-19, provide information on drug options, bring science to the community, and improve minority access to the best cancer care. He added that, while the pandemic has brought a chill to clinical trials nationally, the FDA has been helpful in providing guidance to institutions conducting them.


Oyer noted that the joint ACCC-ASCO minority initiative is "looking for interventions that will make a difference at the community level." Needed, he said, is a change in the trial ecosystem to improve patient acceptance, such as through the use of trusted community ambassadors.


The 2019 ACCC Trending Now in Cancer Care Survey listed the top three challenges to offering patients clinical trials: staff resources and training (53%), program infrastructure (50%), and lack of patients' understanding of the clinical trial process (46%). Oyer recommended some guidelines for community practices considering undertaking clinical trials:


* be clear about the vision;


* confirm organizational capabilities for trials;


* support, train, and recruit the people and skills needed;


* alter the work environment (e.g., by additional time and support); and


* align cost and reward (the reward may be additional time, not money).



"When you plan any new project, it begins with vision," stressed Oyer. "Everybody needs to understand who does what." He recommended that community practices find out whether there is an institutional review board (IRB) at their center and whether there is safety training for staff. He also said he favors standardization of the IRB approval process to make it less of a barrier for community practices, and decentralization of trials to take them where the patients live.


The ACCC conference also addressed health provider resilience in the stressful era of COVID-19. In a keynote talk, Greg Hiebert, MBA, leadership coach and founder of Leadership Forward, asked meeting attendees to consider one question: "Who do I want to be because of COVID-19?"


He advised cancer team members to let go of things they have no control over, and suggested seven self-care practices to build resilience:


1. cultivating positive emotion;


2. living with greater purpose and meaning;


3. deepening one's social bonds;


4. reflecting and expressing gratitude;


5. promoting hope and optimism;


6. being mindful, through meditation, music or prayer; and


7. body movement or exercise every day.



Quality Cancer Programs

Since 2011, ACCC has recognized innovative community cancer programs that have improved the quality of care. Among the featured programs at this conference were the following, which received 2020 ACCC Innovator Awards.


Shifting chemotherapy administration from the inpatient to outpatient setting improves care and saves money.


At the University of Arizona Cancer Center (UACC), Banner- University Medical Center Tucson, a multidisciplinary cancer care team identified chemotherapy regimens that could be safely transitioned from the hospital to the outpatient setting-its ambulatory clinics. The task of analyzing which specific chemotherapy regimens could be safely given in the outpatient clinics took a full year, said Ali McBride, PharmD, MS, BCOP, Clinical Coordinator of Hematology/Oncology at UACC. He noted that the shift required a great deal of provider and patient education on potential side effects and toxicities. The team developed a workflow for each chemotherapy regimen to be given in the outpatient clinics.


The shift resulted in a much better quality of life for patients, said McBride, ACCC Immediate Past President. "They were able to actually sleep at home at night and be with their family," he said. Other benefits included decreased patient bed stay, reduced infection rates, improved access to care, and decreased overall cost of care-an estimated savings of $6 million.


"We were able to improve the patient experience," said Daniel O. Persky, Professor of Medicine at the University of Arizona College of Medicine, where he is Associate Director of Clinical Investigations and the Therapeutic Development Program, Director of the Clinical Trial Office, and principal investigator of the Lymphoma Clinical Research Team. Persky noted that, in the era of the COVID-19 pandemic, reducing the risk of hospital exposure to the virus for cancer patients was a major plus.


Persky said the shift from inpatient to outpatient setting was very much a team effort. "To accomplish anything in medicine it takes a team," because the members of the team contribute different abilities, skills, and expertise.


McBride agreed, noting the team that developed the processes for the chemotherapy transition included financial staff, nurses, nurse coordinators, nurse practitioners, physicians, advanced practitioners, and pharmacists. His theme as ACCC President was Collaborate. Educate. Compensate: A Prescription for Sustainable Cancer Care Delivery. He said he was happy that other community cancer centers have replicated the Arizona experience, thereby improving patient care.


Creating a community-based cardio-oncology clinic lead by nurse navigators.


At the Franciscan Health Cancer Center in Indianapolis, a cardio-oncology clinic was born from a collaborative effort to proactively help improve the quality of life of oncology patients in treatment who are at risk of cardiac problems.


"It's a blend of oncology and cardiology," said cardio-oncology nurse navigator Kerry Skurka, RN, BSN, of the clinic.


"We know that the two diseases, cardiovascular disease and cancer, co-exist in many patients, and we know that some of our cancer treatments can be toxic to the heart," said Vijay Rao, MD, PhD, FACC, FASE, FHFSA, Director of CardioOncology and Co-Director of the Heart Failure Program and Anticoagulation Clinic at the cancer center. "The nurse navigator is the vital role for our program."


He added that nurses make sure "patients don't get lost in a large health system. Our goal is to prevent the cancer survivor of today from becoming the heart failure patient of tomorrow."


Skurka, a cancer survivor, said she watches the patients closely and determines what kind of cardiac surveillance they need. The clinic is housed within the cancer center, which she said makes it easier to follow the at-risk patients in cancer treatment.


Rao noted that the program allays patient fears and provides a "shoulder to lean on." He said the administration backed this collaborative program, which started with manual chart mining to identify cancer patients at risk of cardiac problems. "Our team grew because more people became aware of the clinic as we educated them," said Skurka. "The difference this clinical service can make for cancer patients is astounding."


The Franciscan Cancer Center is now sustained by robust referrals from health providers actively looking for the specialized expertise of cardio-oncologists. It manages the cardiotoxic side effects of cancer therapies for more than 1,000 patients.


Reducing ED visits and hospital admissions after chemotherapy with predictive modeling of risk factors.


Mercy Cancer Care at Mercy Hospital in St. Louis used retrospective data to develop and implement a predictive algorithm that stratifies patients following outpatient chemotherapy according to their 30-day risk of hospital admission or emergency department (ED) visit. Now a daily dashboard report uses real-world data to identify patients as high-, intermediate-, or low-risk. The dashboard risk scores are then used to proactively manage patients with referrals to such services as social work, dietitian consultation, or evaluation for possible home care assistance.


"Right now it's a self-reporting process," said Michelle Smith, DC, Director of Oncology Services at Mercy Cancer Care. "We use the model so we can intervene with high-risk patients." At Mercy, the staff says that "today's data changes tomorrow's care."


Smith said adopting this quality improvement program at Mercy allows proactive management of patients within 30 days of receiving outpatient chemotherapy under the OP35 bundling payment initiative that the Centers for Medicare & Medicaid Services (CMS) put into effect this year under its Hospital Outpatient Quality Reporting Program.


Using technology to identify patient comorbidities and reduce hospital and ED admissions.


Tennessee Oncology is participating in several value-based programs, which led to an effort to look for ways to reduce the high-cost hospital use of its cancer patients, said Natalie Dickson, MD, President and CMO of Tennessee Oncology. In these value-based programs, "our success requires that we reduce hospital visits and emergency department utilization," said Dickson.


In an effort to accomplish those reductions, Tennessee Oncology used data from the Oncology Care Model launched by CMS to identify three comorbidities that led to markedly higher rates of unplanned ED visits and hospitalizations, said Larry Bilbrey, Care Data Systems Manager of Tennessee Oncology. These are COPD, congestive heart failure, and diabetes mellitus. Then the practice developed targeted management algorithms that proactively address these conditions to provide the best care.


Today, care coordinators use these algorithms to screen, identify, and help manage at-risk cancer patients via the care management platform, either by patient-initiated contact, such as telephone triage or through a patient health portal, depending on a patient's comfort level with this technology. For cancer patients admitted to the hospital or ED, admission software provides real-time data to the practice to improve patient management and reduce hospital length of stay and readmissions. Data on the patients with co-morbid conditions can be given to patient navigators so they can intervene proactively with these cancer patients to prevent hospital use and improve their quality of life.


Bilbrey said his advice to other practices that also want to reduce hospital use through data is "don't give up. What you're looking for is out there somewhere." He noted that Tennessee Oncology had been "chasing the data" for awhile that would make a difference in reducing ED visits and hospitalizations. Dickson added that her advice is for practices to focus on what is most important to them in finding ways to reduce preventable costs.


Peggy Eastman is a contributing writer.


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