Impact of Remote Symptom Monitoring With Electronic Patient-Reported Outcomes on Hospitalization, Survival, and Cost in Community Oncology Practice: The Texas Two-Step Study

PURPOSE

There is raising interest to implement electronic patient-reported outcomes (ePROs) for symptom monitoring to enhance the quality of cancer care. Step 1 of the Texas Two-Step Study demonstrated successful implementation of an ePRO system in >200 sites of service of a large community oncology practice. We now report step 2 of this study which evaluates the impact of ePROs on outcomes among patients enrolled in the Centers for Medicare & Medicaid Services' Oncology Care Model (OCM) program.

METHODS

This observational study focused on patients with metastatic cancer enrolled in OCM at large community oncology practice located in Texas between July 2020 and December 2020. Patients who completed ≥1 survey via the ePRO tool were included in the study group and were propensity score matched with patients in a control group. Adverse events (AEs; hospitalizations, emergency department visits, deaths) and total cost of care were a priori study outcomes. Mann-Whitney U and chi-square tests compared continuous and categorical variables, respectively, with multivariable logistic regression for adjustment of covariates.

RESULTS

Of 831 patients with metastatic cancer, 458 matched patients (229/group) were identified, with 52% male and a mean age of 74 years. Mean total AEs were lower in the study group compared with control (0.98 v 1.41; P = .007), with decreased hospitalizations (20% v 32.5%; P = .002), emergency visits (38.4% v 42.3%; P > .05), and deaths (11.8% v 16.6%; P > .05). Average number of hospitalizations was lower (0.28 v 0.52; P = .003) with reduced mean duration of hospitalizations (1.9 vs 3.2 d; P = .03). The total cost of care was reduced by an average of $1,146 per member per month.

CONCLUSION

Symptom monitoring with ePROs improved quality and value of cancer care delivery by reducing hospitalizations, emergency visits, and deaths while lowering cost of care in a large oncology practice.

Remote triage and the oncology patient experience

297

Background: Investments in infrastructure to enhance care delivery are often partnered with practice participation in alternative payment model contracts and innovative care delivery models. Oncology nurses routinely are physically located in a cancer practice. We sought to understand the impact of centralizing resources to work remotely building upon triage pathways already in place on staffing and symptom call resolution with the goal of optimizing outpatient symptom management and patient satisfaction. Due to a national RN shortage and a historical high number of RN vacancies in oncology, we thought this this innovative staffing solution may attract, retain, and elevate the role of RNs. Methods: A needs assessment was conducted to evaluate call volumes, staff levels and duties. A gap analysis was performed to determine which duties would be assigned to remote triage versus in person staffing. Some sites had triage; all sites upgraded to new optimization of assessment and management. Standardized evidence based care and communication pathways were implemented. RNs were trained to follow structured workflows for call ticket resolution. A regional pool supported primary triage RNs who were assigned to each site. The model allowed for flexible staffing while building and maintaining relationships with local providers. Additionally, remote triage RNs were given the opportunity to augment their assessment with audio/visual telehealth as needed. Results: In the first 4 months, 9 pilot sites decreased symptom management time by 50%; 1 site decreased by 70% (over 120 minutes down to 27 minutes). Since remote triage began, average resolution times reduced from 2.52 hours to 1.31 hours. One pilot site had an in-person triage position posted and attracted 4 applicants over 4 weeks. When the position was converted to a remote role, 38 applications were received in 1 week. Offering remote triage positions allowed RN recruitment from other states and gave tenured RNs within the organization an attractive new work model. Conclusions: Remote RN work is an attractive opportunity for RNs allowing for broader recruitment of candidates. Removing triage RNs from the clinic site allows them to focus on triage resolution and as a result call resolution times decreased substantially. Standardized communication pathways were developed, rolled out, and optimized in both virtual and in-person Triage RN roles statewide. Adherence to these communication pathways is critical to ensuring timely symptom management resolution and a sustainable workforce.

APPs provide high-quality specialty care in virtual clinic

390

Background: In our team-based approach to care delivery, Advanced Practice Providers (APPs) are a critical component of the care delivery team. In our statewide oncology practice APPs are not available at each site, limiting our ability to provide program visits that enhance patient care and limiting our flexible staffing capacity. APP program visits - Advance Care Planning (ACP), Treatment Review and Coordination (TRC) and Genetics – had limited availability due to the capacity of existing APP staff. We sought to provide both enhancements in patient care with program visits and offer flexible staffing capacity across our statewide practice by using a centralized virtual care clinic model providing high quality specialty care via Telemedicine. Methods: Four APPs were identified and trained to provide full-time telemedicine services statewide under a single collaboration agreement with the Virtual APP Medical Director. Local sites went through a brief onboarding process with the Virtual APP clinic and then submitted requests for appointment coverage by the Virtual APP (VAPP) team. The VAPPs had the same core oncology training, with a few differentiated skills which were matched with coverage requests aligning with their skill sets. To ensure continuity of care, virtual APP clinic notes were visible statewide in the practice EHR, and local providers were alerted by chart message of significant patient concerns. Results: In the first 3 months of service, the VAPPs completed 1,040 appointments for 12 clinics. The VAPPs conducted 50% Program visits and 50% established patient visits (follow-up, on treatment and urgent care). Conducting the Program visits virtually allowed patients to invite family members from any location to join the appointments virtually. The Urgent Care capability was not used frequently in the first 90 days of service, but may still grow in the future. Conclusions: The Virtual APP program ensured oncology patients received high quality, timely care through 1,040 completed visits. This prevented delays in care, resolved staffing challenges, expanded care, and supports virtual care in oncology. This program ensures APPs are available when and where needed and allows them to efficiently serve multiple clinics. The VAPPs provided education, assessment, prevention, and management of toxicities in a flexible manner.

Impact of statewide telemedicine support model in a community oncology practice

391

Background: While there was broad adoption of telemedicine during the COVID-19 pandemic, optimizing the interaction for patients and the clinical team remained a challenge. We sought to optimize delivery of telemedicine services to provide more efficient and effective patient care. Target areas of concern for improvement were scheduling, staffing, communication, technical challenges with operating the platform, a high cancellation rate, and limited copay collections. Methods: A team of 8 virtual Patient Service Coordinators (VPSCs), 8 virtual Medical Assistants (VMAs), and an RN clinical manager was created to work remotely from home to serve Providers at 8 clinics. VPSCs performed check-in duties, demographics, copay collection and technology trouble-shooting with patients. VMAs performed medical intake (medication reconciliation, depression screenings, and vital signs) with real-time EMR input. VMAs stayed in-touch with patients to communicate Provider delays. Standardized communication pathways connected virtual teams with in-clinic teams. The clinics selected to participate in the TMS program were conducting 29% - 50% of E&M visits by telemedicine. The goal of the TMS program was to reduce stress and burnout, as well as relieve in-clinic staff of telemedicine duties giving them capacity to address in-clinic COVID related staff shortages. Results: The TMS Program supported 15,500 visits (11/15/21 – 5/31/22) and increased upfront expected copay collection from 9% pre-program to 100% post program. The program reduced the time for first contact on video from 18 minutes to 1 minute and reduced the telemedicine cancellation rate by 3%. The supported TM cancellation rate was 7% lower than in-person visit cancellation rate. A geographically distributed work from home team was able to support a 66% increase in visits during inclement weather days which allowed visits to be completed that would have otherwise been canceled due to clinic closures. Additionally, the TMS program relieved workload for in-clinic staff and the VPSC and VMA positions proved highly desirable to the eligible workforce. Conclusions: The TMS Program improved patient connectivity and experience, increased upfront co-pay collection, decreased burden on in-clinic staff, allowed continuity of care during inclement weather, and was an attractive work option for staff. Due to its success, the program moved past pilot phase into an operational program.

Decreases in emergency department and hospitalization visits over 5 years of the Oncology Care Model

64

Background: In the last five years of the Oncology Care Model (OCM) our community oncology practice developed standardized processes throughout the practice to impact hospital and emergency department (ED) utilization. OCM feedback reports were evaluated and compared to practice baseline data to assess the effectiveness of these interventions in improving patient care. Within the practice continuous tracking allowed for timely reviews and process improvement. Methods: A multimodal triage approach was created, including development of individual patient treatment plans and weekly clinical team huddles where new treatment patients or high-risk patients were discussed. The “Call Us First” campaign was initiated through wallet cards. These cards were provided to patients outlining regimen details and indications for patients seeking urgent or emergent medical care. An improved triage program with Navigating Cancer (NC) reduced call back times to patients regarding patient symptoms and care needs, increased faster symptom management and decreased ED visits. Additionally, nursing check in calls were made to patients after initial chemotherapy treatments and hospital admissions. These statewide programs were rolled out through a systematic process over the first year of the OCM. Results: Admissions for the practice’s OCM patients were 22% in 2015 and decreased to 17% in 2021. For the practice’s OCM population in 2015, the baseline ED visits were 16% and decreased to 14% in late Fall 2021. Home health utilization increased from 17.9% at baseline to 22.3% after five years. Long term care days decreased from 10.7 days to 4.5 days. Skilled nursing facility days decreased from 67.6 days in 2015 to 36.80 days in 2021. By comparison, overall national OCM practices had similar declines in ED visits and hospital admissions. Conclusions: Through OCM participation there were systematic changes reducing ED visits and hospital admissions over five years. We believe that early intervention projects enable patients to avoid ED/hospital visits. Home health care visits may have contributed to less admissions. Patient outcomes were favorably impacted by the practice wide processes guided by the feedback reports. Future iterations of value-based care are undecided, and practices will build on these enhancements.

Value-based care outcomes in pancreatic cancer patients with and without access to registered dietitians: A retrospective cohort study of patients enrolled in the Oncology Care Model

e16249

Background: Patients with pancreatic cancer face many nutrition-related concerns, although few guidelines exist to direct clinical nutrition services in this population. Examining quality outcomes for patients in clinics with and without access to a Registered Dietitians (RD’s) can help examine the contributions of RD’s in this area. Methods: A retrospective cohort design was used to compare Total Cost of Care (TCOC), hospital admissions and Length of Stay (LOS), and Emergency Department (ED) and Observation visits for patients with pancreatic cancer who were enrolled in the Oncology Care Model (OCM) during Performance Periods (PP) 1-6 (July 1, 2016–June 30, 2019). Patient deaths during the initial episode of care were also examined. Patients from a geographically concentrated metropolitan hub were divided into cohorts based on clinic access to an RD. Each patient’s initial six-month OCM episode of care was used for analysis. Results: Of the 389 OCM patients identified with pancreatic cancer from PP1-6, 203 were treated at 10 clinics with an RD and 186 in 17 clinics without an RD. In the RD cohort, 43.3% of patients were admitted to the hospital with an average LOS of 8.9 days. By contrast, 52.2% of patients in the non-RD cohort were admitted to the hospital with an average LOS of 10.0 days. TCOC for the 6-month episode was lower in the RD cohort at $37,185 versus the non-RD cohort at $40,907. During the initial 6-month episode of care, 37% of patients in the non-RD cohort died during the initial 6-month episode vs only 28% in the RD cohort. A higher percentage of patients in the RD cohort (35%) had ED or Observation visits, compared with the non- RD cohort (32%). Conclusions: Amongst OCM patients with pancreatic cancers, treatment at a clinic with an RD was associated with lower TCOC, reduced LOS for patients that were admitted to the hospital, and lower percentage of deaths in the first 6-month episode of care. The percentage of patients with ED and Observational visits was slightly higher in the cohort that had access to an RD. This analysis shows the potential benefit of RD services in an outpatient setting and justifies further study. Future multilevel modeling will evaluate the statistical significance of these results.[Table: see text]

Evaluating mass implementation of digital health solutions to improve quality and reduce disparities in a large multisite community oncology practice

1507

Background: There is a priority to accelerate the delivery of digital health solutions (DHS) to provide patients with enhanced means for accessing care, but lack of understanding of their utility in certain populations. There are concerns that equitable adoption translate into disparities. We sought to implement a portfolio of DHS across a large practice and characterize engagement across populations to enhance clinical informatics solutions that support care delivery. Methods: This is a retrospective evaluation of cancer patients who engaged with a portfolio of DHS between March 1, 2019 and January 15, 2022. We included four tools with opt-in and opt-out functionality: (1) a care management (CM) platform utilized by clinical staff to manage patient activities, (2) an electronic patient-reported outcomes (ePRO) remote monitoring program for tracking symptoms and oral adherence, (3) a patient portal (PP) for securely accessing patient health records, and (4) digital education (DE) for patients regarding disease and treatments. The engaged population was defined as the number of enrolled patients with at least one (1) record of triage activity, (2) completed ePRO assessment, (3) PP login, and (4) DE read activity, for each tool, respectively. The start of the index period was adjusted based on the first go-live date of each tool. We evaluated factors (age, gender, race/ethnicity, preferred-language, marital status, and distance from clinic) associated with patient engagement using Chi-Square test and multivariate logistic regression. Results: This analysis included a total of 267,375 unique patients. Of the enrolled population per tool, 172,840 (73.6%), 9,938 (67.7 %), 49,771 (79.2%), and 12,044 (56.9%) patients were engaged in CM, ePRO, PP and DE, respectively. The majority (>50%) of engaged patients were female, White and non-Hispanic/Latino, English-language, and aged 61-80 yrs. After adjusting for covariates, we observed that White and non-Hispanic/Latino [(CM: OR 1.15, ePRO OR 1.46, PP: OR 1.48, and DE: OR 1.36) and English-language (CM: OR 1.2, ePRO OR 1.67, PP: OR 1.8 and DE: OR 1.89) patients were significantly (p-value <0.001) more engaged compared to their counterparts. Male patients were less likely to be engaged in CM (OR: 0.79) and ePRO (OR: 0.65) but more engaged in PP (OR: 1.1) compared to females. No significant difference was observed in engagement between non-rural (<20 mile) vs. rural (≥ 20 miles) and in all age groups 21-40, 41-60, 61-80 and >80 years as compared to reference age of 0-20 years for any digital tools except CM. Conclusions: DHS can be used to support the cancer patient journey and we demonstrated high utilization in an array of sociodemographic variables in our population. However, tools designed and implemented with different populations in mind to reduce staff burden and lessen the digital divide should be further explored.

Analyzing patient engagement with digital health tools to facilitate equity across a large statewide community oncology practice

1575

Background: Digital health solutions (DHS) allow for enhanced remote communication between patients and clinical staff and the COVID-19 pandemic has brought these tools to the forefront of care delivery. Once adopted, barriers to adequate utilization still exist. Given the important need to decrease digital divides, and the diversity of patients and care settings across our clinic’s 220 sites of service, we sought to understand how utilization of oncology DHS may be limited among certain populations. Methods: We investigated utilization among cancer patients who enrolled and engaged with a portfolio of DHS between March 1, 2019 and January 15, 2022. This portfolio includes three tools: (1) an electronic patient-reported outcomes (ePRO) remote monitoring program for tracking symptoms and oral adherence, (2) a patient portal (PP) for securely accessing patient health records, and (3) digital education (DE) for patients regarding disease and treatments. ePRO completion rate, average number of PP logins, and DE read rate were used as measures of utilization for each tool, respectively, and compared among patients with different age (< 65 and ≥65 years), language preference [English (EL) or Spanish (SL)], and distance from clinic (non-rural: < 20 miles OR rural: ≥20 miles). Mann-Whitney U and Chi-Square tests were used to compare continuous and categorical variables, respectively. Results: This study included a total of 77,347 unique patients representing 651,004 digital encounters. 9,938 patients engaged in ePRO, 49,771 patients in PP, and 12,044 patients in DE. Engagement across all DHS was high in patients of age group < 65 (ePRO: 72.7%, PP: 79.67% and PE 54.7%) as compared to ≥65 years, but the ePRO completion rate is high in ≥65 age group (59.0% vs 55.6%), whereas no significant difference was observed in the PP login activity and DE read rate. EL patients were significantly (p-value < 0.01) more engaged (ePRO 68% vs. 54%, PP: 80% vs. 62%, DE: 57% vs. 37%) and had higher digital utilization (ePRO completion rate: 57.31% vs 53.23%, average PP logins: 7.48 vs 7.14 and DE read rate: 96.2% vs 90.8%) than SL patients across the DHS. Patients living in rural areas comprised roughly 25% of the population and participated across tools similarly as patients living in non-rural areas (ePRO 67% vs. 69%, PP: 79% vs. 79%, DE: 56.9% vs. 56.8%). Utilization of the portfolio was variable based on rural vs non-rural status (ePRO completion rate: 56.3% vs. 57.4%, average PP logins: 7.9 vs. 7.3, DE read rate: 96.02.7% vs 96.3%). Conclusions: Despite variable engagement based on age, language, and rural status across the portfolio, patients within these populations continue to utilize the DHS. How we understand and explore enhancements to DHS remain under investigation for tool optimization for patient-specific barriers to care.

Patient and clinician perceptions of a digital patient monitoring program in the community oncology setting: Findings from the Texas Two-Step Study

189

Background: Digital monitoring strategies that include electronic patient reported outcomes (ePRO) measures to monitor symptoms among cancer patients have been shown to be effective in improving patient outcomes in a large academic setting and across several smaller multi-center trials. However, demonstration of clinical utility in the real-world setting must incorporate patient and provider perspectives of ePRO programs to ensure successful implementation. We sought to understand perceptions among patients and clinicians in ePRO digital symptom monitoring program. Methods: Texas Two-Step is an ongoing hybrid implementation-effectiveness study of Navigating Cancer’s ePRO digital monitoring program at Texas Oncology. Patients initiating new systemic therapy for their cancer diagnosis were introduced to the program by their oncologist and enrolled in the program by nursing staff for weekly reporting of symptoms based on a modified version of NCI’s PRO-CTCAE instrument. Feedback surveys were administered to both patients and clinic staff after 6 months of implementation of the program to evaluate the overall experience with the program. Results: 1040 (23.5%) patients and 215 (12.4%) clinicians completed the feedback survey. Of the patient responders, 90% found the program very or somewhat easy for reporting symptoms, 85% moderately-extremely beneficial for having symptoms addressed, and 84% moderately-extremely interested in utilizing the program for future treatments. Of the clinician responders, 73% indicated that that they had a good understanding of the benefit of the program; 70.6% felt confident in their ability to interpret patients’ ePRO responses; 80.3% felt confident in their ability to discuss the program with patients; 71.2% confident in their ability to counsel patients based on ePRO responses; and 55.3% felt the program enhanced communication with patients. Additionally, 59% of clinicians felt the program was beneficial for patients. Conclusions: Patients have a more favorable perception of the benefit of the ePRO program than clinicians. Methods to reduce staff burden and reinforcement of program benefits during training and implementation are imperative to improve clinical utility and will be studied further as the program is optimized. As implementation occurred during the COVID-19 pandemic, this may impact perceptions regarding the tool.

Implementation of a mortality risk predictive analytics model

211

Background: Improving the quality of End of Life (EOL) care continues to be a challenge. Enhanced prognostic awareness is critical for all members of the clinical team. In December 2020, The McKesson Advance Care Planning Enrollment eXtended (APEX) mortality risk predictive analytics model was implemented to improve prognostic awareness in OCM population and improve the timing of initiation of end of life care. (See ASCO 2021 abstract #1560). Methods: The APEX tool was provided in collaboration with the McKesson/US Oncology network analytics team. A process was established for dissemination of the report information. In the pilot, 12 practice locations with varying community landscapes, socio-cultural dynamics, and site clinical personnel resources were selected. At each site clinical leads and physician champions were selected. Education was provided on the tool, prognostic variables, and appropriate interventions. Biweekly, each site was provided a list of stratified patients based on their risk of mortality within the next 90 days. Patients that were identified as “very high” or “high” risk were reviewed by the clinical teams and discussed in routine huddles. Physicians and teams reported their planned interventions before and after mortality risk identification. Results: In the pilot, 105 patients were identified as very high or high risk. Reported interventions included the option to continue treatment, ACP Discussion, hospice referral/enrollment, palliative care referral, or continue close monitoring. Prior to the report, 14 identified patients were admitted to hospice and 30 patients had 1 or more advance directives documented. For 26 patients, treatment changes occurred including hospice enrollment, reduction in chemotherapy dosage, change in regimen, or initiating intensive monitoring. 23 patients indicated on the report expired in the interim between generation of the report and receipt by the clinic. No changes in treatment were made in 22 patients. There was physician reported disagreement with the mortality risk assessment in 4 patients. Conclusions: We describe implementation of a mortality predictive model in our practice. The care teams found the tool useful to identify patients at high risk of mortality. Interventions were varied and we will track the outcomes based on intervention. We are using the information from the pilot to continue refining the tool and implementation.

Implementation of Electronic Patient-Reported Outcomes for Symptom Monitoring in a Large Multisite Community Oncology Practice: Dancing the Texas Two-Step Through a Pandemic

PURPOSE

Among patients receiving chemotherapy, symptom monitoring with electronic patient-reported outcomes (ePROs) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established, warranting evaluation in community cancer practices. We present implementation findings of ePRO symptom monitoring across a large multisite community oncology practice network.

METHODS

Patients initiating a new systemic therapy at one of the 210 practice sites at Texas Oncology were invited to use the Navigating Cancer ePRO platform, with stepped-wedge implementation from July to December 2020. Participating patients received a weekly prompt by text message or e-mail to self-report common symptoms and well-being. Severe self-reported symptoms triggered a real-time notification to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability.

RESULTS

Four thousand three hundred seventy-five patients planning systemic treatment were enrolled and participated. Seventy-three percent (1,841 of 2,522) of enrolled patients completed at least one ePRO assessment. Among these individuals, 64% (16,299 of 25,061) of available weekly ePRO assessments were completed. Over a 10-week period, compliance declined from 72% to 52%. Barriers currently being addressed include lack of a second reminder text or e-mail prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included ease of use and patient and staff engagement on the importance of PROs for symptom management.

CONCLUSION

ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.

Improvement in incident resolution time with implementation of an electronic patient management solution at a community oncology practice

1578

Background: Value-based care models such as the Oncology Care Model incentivize practices to reduce hospitalizations and emergency department (ED) visits. Texas Oncology found that most ED visits occurred during regular business hours. Prolonged patient call back times were consistently rated poorly on satisfaction surveys and often led to ED visits for symptoms that could be managed in our offices. We partnered with Navigating Cancer (NC) to implement an electronic patient management technology solution. Methods: For each of our 200 locations, call volume was estimated based on clinic volume. We then reallocated or hired dedicated triage nurses and operators. Incoming calls were entered into the NC dashboard by operators as incidents which were routed based on symptom priority following system generated prompts. Incident volumes and resolution times were tracked. We instituted PDSA cycles at all locations with a goal of less than 90-minute resolution of symptom-related incidents Utilizing the electronic dashboard allowed us to continue this initiative during the COVID-19 public health emergency as our staff could work remotely. Nurses were able to document if a potential ED visit was avoided. These data points allowed our practice to establish comprehensive and strategic actions plans for quality improvement. Results: We finalized implementation of the system in February of 2020. Total incidents for 2020 were over 1 million, averaging over 5000 per location. Resolution time for all incidents started at 3.2 hours pre-implementation and improved to 2.2 hours in December of 2020. Resolution times for symptom-related incidents started at 2.3 hours pre-implementation and ended at 1.5 hours in December of 2020 with over 60% resolved under one hour. 8% of symptom-related incidents resulted in definite or probable ED avoidances by nursing assessment. Shortness of breath, vomiting, chills, and weakness were the top symptom types addressed for ED avoidances. Conclusions: An electronic patient management solution with PDSA cycles of quality improvement can markedly reduce call back times, especially for symptom related calls. We believe managing symptoms in a timely fashion will lower ED visits and hospitalizations as well as improve patient satisfaction. We will report on these outcomes once available.[Table: see text]

Implementation of electronic patient-reported outcomes for symptom monitoring in a large multi-site community oncology practice

12103

Background: Among patients receiving chemotherapy, symptomatic adverse event monitoring with electronic patient-reported outcomes (ePRO) is associated with improved clinical outcomes, satisfaction, and compliance with therapy. Standard approaches for ePRO implementation are not established warranting evaluation in community cancer practices. Objective: Evaluate implementation of ePRO symptom monitoring across a large multi-site community oncology practice network. Methods: Patients initiating a new systemic therapy at one of 210 practice sites in the Texas Oncology Practice were invited to use in the Navigating Cancer ePRO platform, with rolling implementation from July-December 2020. Participating patients received a weekly prompt by text message or email (patient choice) to self-report common symptoms and well-being via web or smartphone. Severe self-reported symptoms triggered a real-time notification alert to nursing triage to address the symptom. Enrollment and compliance were systematically tracked weekly with evaluation of barriers and facilitators to adoption and sustainability. Results: 4375 patients planning systemic treatment enrolled and participated, with baseline characteristics are shown in Table 1. 73% (1841/2522) of enrolled patients with follow up completed at least one ePRO assessment, and among these individuals, 65% (8762/25061) of all available weekly ePRO assessments were completed. Over a 10-week period, compliance with weekly symptom reporting declined from 72% to 52%. Patients on oral therapy had higher compliance rates overall. Barriers currently being addressed include lack of a second reminder text/email prompt, inconsistent discussion of reported ePROs by clinicians at visits, and COVID-related changes in workflow. Facilitators included patient and staff engagement on the importance of PROs for symptom management. Conclusions: ePROs can be effectively implemented in community oncology practice. Utilization of ePROs is high, but diminishes over time without attention to barriers. Ongoing work to address barriers and optimize compliance are underway.[Table: see text]

Can we keep patients home? Decreasing hospitalizations in the oral chemotherapy patient

294

Background: The Oncology Care Model (OCM) pilot includes all types of cancer with an aim to test whether additional funding for enhanced services and financial incentives to improve quality and efficiency, could reduce Medicare spending while maintaining or improving quality for a broad array of cancer types. Patients taking oral chemotherapy are included in the OCM. Often these patients require hospitalization due to side effects,decreased access and ability to communicate with providers. Limited documented strategies exist showing how to decrease hospitalizations in patients with cancer. The aim of this study was to decrease the hospitalization rate of oral chemotherapy patients at five sites by improving access to care and communication via establishment of phone triage nursing management. Methods: The aim of this project was to reduce hospitalizations for oral chemotherapy patients being treated at home over an eight month period. The Model for Improvement served as the research framework and design for this improvement project. The model includes identifying, defining and diagnosing a problem, before developing solutions and implementing interventions that are anticipated to solve the identified issues. Plan, Do, Study, Act (PDSA) cycles were utilized to develop and test changes in support of the oral chemotherapy patients. Five clinical sites affiliated with a community oncology practice in Texas collaborated with a Patient Support Service (PSS) nursing call center. Results: Implementing the PSS center resulted in a lowered number of monthly hospitalizations over eight months in patients receiving outpatient oral chemotherapy as compared to monthly volume of hospitalizations over eight months before implementation while demonstrating positive patient satisfaction with the oral regimen. Conclusions: This quality initiative found that OCM patients receiving oral chemotherapy can be supported to remain in their homes while decreasing unnecessary hospitalizations through the establishment of a PSS center. Through support systems for out-patient oncology patients, outcomes can be improved, unnecessary hospitalizations decreased, patient satisfaction sustained, and overall cost of care reduced.

Medically integrated pharmacy: A team-based approach to improve oral oncolytic therapy for cancer patients

140

Background: The use of oral oncolytic therapies in the treatment of cancer is rising dramatically.　Cost barriers to obtaining drugs and side effects of therapies lead 1 to poor adherence to oral regimens resulting in detrimental outcomes. External specialty pharmacies have attempted to assist patients but this often leads to further fragmentation of care. We report on the performance of a medically integrated pharmacy within a large community oncology practice to achieve better patient outcomes. Methods: The Texas Oncology medically integrated pharmacy (MIP)consists of oncologists, oncology nurses, advanced practice providers, and specially trained pharmacy staff utilizing real-time access to the patient’s electronic medical and pharmacy records when oral therapy is prescribed.　The team processes　prior authorizations and patient assistance requests,　ensures drug delivery, provides education, monitoring, and follow up of side effects for oral therapies. The care team is available to provide early intervention and side effect management. Treatment initiations, dose adjustments, and treatment discontinuations are communicated seamlessly in real time. Results: Texas Oncology MIPs process over 14,500 prescriptions annually with a 99% prior authorization approval rate. Service is timely with a representative sample of 4 practices showing 64% of prescriptions filled within 24 hours of prescribing and 72% filled within 72 hours. Prior authorization and patient assistance were the leading causes of delays. The patient assistance team processes over 3,200 requests annually with over $121 million copay assistance obtained. Adherence to therapy within Texas Oncology is over 92% for the 7 most commonly prescribed oral oncolytic drugs.　Patient satisfaction surveys reveal 96% satisfaction with the medically integrated pharmacy. Conclusions: The MIP is a fully aligned team based approach for the delivery of oral oncolytics. A medically integrated pharmacy provides timely access, copay assistance, monitoring and management of side effects resulting in increased adherence to therapy and an overall improvement in quality and satisfaction.