Darcy Malard Johnson, PharmD

“Chemotherapy.” “Radiation.” “Progression.” “Metastatic.” These words confront and often overwhelm patients with new diagnoses of cancer. Health care is challenging enough for those of us who work within it daily, let alone patients who just learned they have cancer, to navigate. What can health systems do to provide a seamless journey during a time of uncertainty?

With an oncology service line (OSL), a patient with cancer finds coordinated care between the many health system settings they must navigate, including hospitals, clinics, infusion centers, pharmacies, and ancillary services. Coordinated care improves the patient experience; without an OSL, the burden to coordinate between sites too often falls on the patient.

A service line refers to the integration of a health system’s services based on patient need rather than professional discipline or physical buildings. This model brings together all the relevant system services for a specific patient population, making a more seamless patient experience possible.

Fairview Health Services, based in Minneapolis, Minnesota, has been working to move from a regional management model to a service line model. Together with our partners at the University of Minnesota, our system has created 10 service lines that transcend acute, postacute, and ambulatory settings. Having a service line means that integrated care teams in all settings not only coordinate with each other but also work together in the same way, with the same processes, policies, and leadership, to produce better outcomes for patients.

Pharmacy is integrated with every system service line but especially oncology. Our system’s OSL, formally called Cancer Care Service Line, came together in 2010 before our health system adopted service lines more broadly. An OSL allows for allows for better care and a superior patient experience by creating efficiencies, enabling innovation, and preparing resources and processes for the shift toward oral chemotherapy.

Creating Efficiencies and Working Across Disciplines 

An OSL reduces duplication and administrative and clinical variation in a health system, allowing pharmacists to spend more time providing and influencing patient care. Without an OSL, they might be accountable to different policies and reporting structures or need to spend extra time learning site-specific variations. One example in our system involves a consolidation of chemotherapy administration policies. Historically, each facility had a unique policy, but to reduce variation and the potential for harm, we engaged stakeholders to create a single policy that is used at all locations.

This model creates an efficient structure of leadership and decision makers who allow staff to quickly identify and solve problems. A key management activity at Fairview is a daily, tiered huddle process beginning with teams at the front lines, rising through management levels, and ending with the chief executive office. Our huddle structure creates visibility on each day’s work, sparks conversations to escalate and resolve any concerns, and provides an opportunity to recognize great work.

For oncology and pharmacy, this daily collaboration means we can quickly identify our patient census for the day and collaborate on opportunities. It also means that pharmacists in our hospitals and cancer clinics meet regularly with key clinical and business counterparts. This allows us to build relationships and trust across disciplines and solve problems with input from the whole care team.

As we gain efficiencies, our pharmacy resources gain time and space to innovate. If we see an opportunity to do something in a better way, we try it. If it works, the OSL structure helps us bring the improvement to other sites.

Working closely with oncologists and other oncology partners also allows us to collaborate on new treatment opportunities. In 2017, we became one of the first health systems approved to offer chimeric antigen receptor T-cell therapy, an innovative form of immunotherapy that harnesses a patient’s immune system to fight cancer. In late 2018, we became the first health system to bring digital medicine to oral chemotherapy, coencapsulating capecitabine with digital sensors made by Proteus Digital Health to help patients stay on track with their cancer medications.

Having a well-established OSL made these projects come to life. We could engage the right team in a timely manner and had the resources to move the work forward. The whole team is working toward the same vision and goals.

Most important, service lines are about delivering better care for patients. Because providers, nurses, pharmacists, and other care team members work together rather than in silos, our patients don’t have to connect the various elements of their care. We do it for them.

Specialty pharmacy continues to see a shift in cancer care, from infused chemotherapy to oral chemotherapy. Since 2012, more than 50 oral chemotherapy agents have been approved, and more are in the pipeline. Oral chemotherapy should be more convenient for patients because it can be taken at home, but it relies on patient adherence to produce the clinical benefits of prolonged drug exposure. Less frequent visits to the clinic mean fewer opportunities to monitor labs, toxicities, and adherence and make patients more accountable for their care.

Our OSL recognized the need to think ahead for this paradigm shift. The goal was to create an oral oncology experience with the same level of safety checks that we had for patients coming to our infusion centers. In 2011, Fairview launched an oral chemotherapy program—made possible by our OSL&mdash;and created new touchpoints for pharmacists to interface with patients, including those receiving chemotherapy at home. Physicians, nurses, and care coordinators no longer have to take on responsibilities related to drug education or monitoring adverse effects (AEs) once a patient will be starting oral chemotherapy, because the pharmacy manages this. The way we divide our work in the OSL allows more individuals to practice at the top of their license, exercise their expertise, and focus on what they do best for patients.

For pharmacists, this means we are positioned to do much more than prepare and dispense drugs. The efficiencies gained in our OSL structure, in addition to being part of an integrated care network, allow us to reach out to and meet with patients to problem solve, educate, and serve as a resource at every stage.

		Clinic infusion: Pharmacists visit with patients during their infusion appointments, taking advantage of the time to educate them about their therapy and possible AEs. We can also connect face-to-face with infusion nurses.

		Home infusion: We work with patients to coordinate the optimal site of care based on their needs, such as evaluating whether a therapy is safe for home infusion. Being proactive helps us manage infusion chair space and keep some patients in the comfort of their homes.

		Education: Once a patient and their oncologist reach a shared decision on their treatment plan, if it involves oral chemotherapy, pharmacists who are already located in the clinic can join the conversation to provide initial education about the drugs, AEs, and the importance of adherence.

		Phone support: We proactively call patients who are on oral chemotherapy to check on their adherence. We ask targeted questions to determine whether they are experiencing AEs. We can work to resolve any issue with the patients or involve the provider.

		Logistics coordination: Dedicated pharmacy technicians called oncology liaisons reach out to patients who are due for a refill of an oral medication. Together, they talk through the plan and cover details related to shipping, co-pays, and key dates. Having technicians manage this aspect of care relieves pharmacists and nurses from their tasks and affords the technician an opportunity to provide valuable services to our patients.

		Financial assistance: Both our infusion finance team and oncology liaisons provide a concierge-like service related to all aspects of finance, insurance, and billing. They manage all prior authorizations and secure funding for therapies, including making sure site-of-care transitions work smoothly. This dedicated team not only connects patients to assistance programs from manufacturers and foundations but also helps enroll patients and move them through the application process.

		Survivorship: Through our OSL, we have providers who help patients transition back to their primary care provider. Pharmacists partner in this process to help patients and primary care providers understand long-term AEs such as cardiac toxicity so they can be monitored appropriately.

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What can health systems do to provide a seamless journey during a time of uncertainty?