DENVER, CO—Predications for the next 3 to 5 years indicate that 50% of all oncology/hematology treatments will be oral oncolytics. Oncology practices need to develop programs to manage the treatment of patients following these regimens, said Jody Pelusi, PhD, FNP, AOCNP, of Arizona Oncology Associates in Sedona, Arizona, in her presentation at the 2015 Oncology Nurse Advisor Navigator Summit.
Ninety-two oral drugs are currently approved for treatment of cancers, and there are more in the pipeline. Guidelines that support the shift to oral treatment are in place. It is up to oncology practices to take on a philosophy of a team approach to patient- and family-centered oncology/hematology oral treatments. “We have to begin to think about how everyone in the practice has to have a piece of the pie,” explained Pelusi. Her oral medical management program includes 13 specific elements that are consistent for providing quality cancer care.
Although each oncology practice is unique in terms of personnel and skills, oncology nurse navigators have a critical role in matching and supporting the staff for each element. Initiating the process involves evaluating what components you already have in your practice, what are patient and caregiver needs and expectations, what are your staff needs and expectations, and what are the needs and expectations of the practice.
This program has a role for everyone in the practice. It is up to navigators to evaluate what they currently have in their practice, then fill in the gaps and connect the dots.
Staff education This is an important first step. “You cannot provide your service if you don't have a competent staff,” stressed Pelusi. Your staff needs to know the process and what each staff person's role is in that process. Education must be both ongoing and periodically evaluated. In addition, whatever you decide to do in terms of ongoing staff education—in house, self-learning modules, online conferences—make it part of the competencies, suggested Pelusi.
Patient/caregiver selection Not every patient is a suitable candidate for oral drug therapy. Patient/caregiver selection should consider what is going on in the patient's life that could compromise their ability to adhere to an oral drug regimen needs to be in place.
Patient/caregiver education Discuss the treatment options with the patient and the caregiver, as well as the oncology care team. Ensure that patients and caregivers know this is a partnership; they have a role and responsibilities toward the success of their treatment plan.
Pretreatment evaluation Navigators should check for any labs and imaging studies needed for baseline evaluation and dosing, and if there are, see that they are obtained and documented. In addition, evaluate the patient and home environment.
Medical acquisition Navigators will need to work with insurers and oncology pharmacists to complete authorization processes, identify who will fill the prescription, understand the refill policy, confirm when the medication will be delivered to the patient, and determine a start date.
Informed consent This step needs to emphasize the unique characteristics of an oral drug treatment plan, including the patient's role in managing their drug administration, awareness of side effects, and responsibilities to report these effects to the oncology care team. At her practice, Pelusi's team changed the consent forms to incorporate the patient's role in maintaining a successful oral program. “This is a partnership,” she explained.
Treatment plan dissemination A comprehensive treatment plan includes the goal of therapy, timing and dosing of therapy, special considerations, monitoring and follow-up procedures, and symptom management. Copies of the treatment plan should be given to the patient, placed in the chart, and sent to the primary care provider. It should also prepare patients for survivorship, or what they will need when therapy is over.
Monitoring and follow-up The navigator should determine what monitoring and follow-up strategies, such as patient visits to the office, web-based patient portals, phone-based check ups on patient status and the frequency of each.
Ongoing patient/caregiver education Navigators need to make the most of office visits by tying in ongoing education for patients and caregivers with office visits. Work from a check-off sheet that will help ensure consistency and completeness of information, include “unknown” topics such as sexuality, vaccination, etc. Provide information based on the patient's and caregiver's needs in chunks of 15- to 20-minute sessions to avoid overwhelming them.
Document, document, document A comprehensive record from treatment start date to completion of therapy, including trends, side effects, and adherence ensures efficient patient care and provides a complete treatment summary.
Communication Navigators cannot assume every member of the care team—physicians, nurses, and pharmacists, as well as the patient and caregiver—are communicating with each other. Navigators have to keep the lines of communication open between pharmacies, pharmacies and the practice, pharmacies and patients, and the oncology practice and other providers.
Evaluate the process Quality assessment should evaluate patient, caregiver, and staff satisfaction. Consider adherence/persistence; side effects; dose holds/reductions, intensity; and time to first dose.
Policies, procedures, variance reporting Review the policies and procedures to ensure they reflect the needs of oral medication management program. Develop a variance reporting mechanism to support plans that can enhance care.
Pelusi suggests navigators review the guidelines and recommendations, evaluate what they currently have in their practice, get everyone—including patients and caregivers—in developing and evaluating their program, keep everyone informed of findings and process issues, and to trust the process.