Best Practices in Multidisciplinary Care in AML - Episode 7

A Care Team’s Individual Roles When Treating AML

The panel describes the various roles and responsibilities for each member of an AML management care team.

Ryan Haumschild, PharmD, MS, MBA: Danielle, what does the patient journey look like when they interact with the care team? What does a typical care team look like for a patient with AML [acute myeloid leukemia]?

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: It takes a village to take care of these patients. You have your physicians and nurses. We’re constantly working with our pharmacists, dietary, PT/OT [physical therapy/occupational therapy], referring physicians that are coming into the community.

Ryan Haumschild, PharmD, MS, MBA: Are you seeing a lot of those referrals that we talked about, people being referred from the community to those practices, and vice versa?

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: Absolutely. We do see a lot in our practice; we only treat leukemia. A lot of community physicians are treating a variety of malignancies. They come to us just to [double check things]. Going back to the care team, we have resources that a lot of these community hospitals unfortunately don't have access to. We can get drugs faster for patients and get them on the right treatment plan. We have a group of people that help us with that.

Ryan Haumschild, PharmD, MS, MBA: That’s comprehensive care, making sure the right cytogenetics are being done, making sure the evaluations are being done and, if appropriate, referring them back to the community practice to manage the patients. I appreciate your insights, thank you.

We go through managing these patients, and we talked about getting patients to bone marrow transplant, how it provides great overall survival for them and allows them to continue with their journey. We know that some of those patients stay on conventional therapy, and not all will be exposed to some of those intensive therapies. Within that treatment regimen, there's different exposure to chemotherapy along the way orwith oral medicines, and with that comes toxicities. Danielle, I know you do a lot of this. Can you describe your role in managing toxicities in these patients and how you approach it? Everyone might be on an individual-type treatment.

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: With these patients, especially if they're getting induction or consolidation, any intensive chemotherapy, they're coming to the office almost 3 times a week. They're going to require blood transfusions, platelets. If you're symptomatic and anemic, giving a unit of blood will help have a better weekend. [You have to be able to recognize] if they're nauseous or vomiting, having antiemetics available at home, [and then be proactive with] prescribing that. If it is the weekend or late at night, they're not panicked. They can take something and can feel better. It's also important to be asking specific questions to patients. Are you having a fever? Do you have any abdominal pain? It's so often that you're visiting with the patient, and if you're not specifically asking them [if they have a fever], you’ll find out 2 hours later they've been having a fever all night. Asking very targeted questions to patients also helps you manage them more appropriately.

Ryan Haumschild, PharmD, MS, MBA: I like that seeking information from the patient. That's the most important resource that we have when we're looking at these. Dr. McCloskey, I didn't know if you wanted to add anything else.

James McCloskey, MD: Danielle really hit the nail on the head. It just brings up again this idea that we're all a team. Patients develop a relationship with everyone on the team, but probably the closest relationship is with our nurses that spend so much time with [them]. They often gather some of the most valuable information. Across the country, clinical practice has become so busy that the time I get to spend with my patient might be limited. A lot of that information is gathered by our nursing team. It's not at all uncommon. Danielle will tell you that if I go into a room, everything's fine. Then–

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: It's always fine when the doctor goes into the room.

James McCloskey, MD: Danielle has a list of complaints that come up during their conversations.

Ryan Haumschild, PharmD, MS, MBA: I love that emphasis on team-based care because that's exactly where things are headed. There's so much going on that we need a team—nursing, physician, pharmacy, the rest of the allied health care professionals really working together. As we talked about the different roles, you did a great job highlighting the role of the provider and nurse. Dr. McCoy, can you talk about the pharmacist role in AML in terms of treatment selection and the management of toxicities? Innovative pharmacy practices might leverage collaborative practice agreements. Those pharmacists select therapies as part of the treatment and manage some of the adverse events. Talk to me about your experience in managing AML patients and maybe some of the toxicities as well.

Cole McCoy, PharmD: Where does the pharmacist really fall in? I have an established relationship with a lot of our hematologists. They'll lean on me. Is there any hepatic function? Is there any renal dysfunction? How should we dose this medication? We're getting involved there. Earlier, I also talked about a lot of targeted therapies. It wouldn't be a full conversation if we didn't talk about the potential prior authorization and financial toxicity that goes with that. If a hematologist wants to start a medication, sometimes that takes longer. You have to submit for a prior authorization for insurance approval, get insurance approval, and then the medication is expensive. How does the patient pay for that? Is there different manufacturing assistance? Are there grants? We're trying to work with our prior authorization team to help the patient and hematologist, as well as the nurse, get what they need to get. Also, along with the team, we do patient education. At our specific institution, if a patient starts on a new oral chemotherapy, a pharmacist will sit down with that patient and a family member and go through the medication—how to take it, what are the potential toxicities of that treatment, what are the mitigation strategies to help prevent against that. We're involved that, as well as those follow-up phone calls to see how things are going. Is there anything new that came up where we can kind of change avenues? We get involved in the drug accusation but also in meeting our goals of treatment.

Ryan Haumschild, PharmD, MS, MBA: Those follow-up calls always play an important role. As a health system or office dispensing of some of those oral chemotherapy or anti-cancer agents, you have to make sure you're monitoring patients. We can do that in clinic, but we can also do those assessments over the phone and make any titration as needed. I have a question for Danielle. We talked about the nurse’s role. Nurse navigators plays such an important role to getting a patient ready, whether it be for transplant or different therapies. There are so many different vulnerabilities that patients have. Can you talk to me about the role of nurse navigators in clinical practice and any additional management that nurses do as part of that patient care journey?

Danielle Marcotulli, APN, RN, MSN, FNP-BC, AOCNP: We have a few nurse navigators. They're at the front of every phone call. Every call that comes through with adverse events or toxicity for medications or just not feeling well, they triage those. Do they need to come into the office? What can we give them over the phone? Do they need to be admitted to the hospital? Our nurse navigators are also getting our oral medications. They’re sending them to pharmacies, speaking to pharmacists, doing the prior authorizations. If it's coming back with a high copay, they're getting the patient copay assistance. They're back and forth with the patient on delivery. Do we need it at the hospital this week? Do we need it out home next week? They're in charge of all of that for our care.

Ryan Haumschild, PharmD, MS, MBA: It's a huge role, and I think the right patients with the right teams have the best success. Thank you.

This transcript has been edited for clarity.