Background: The advent of oral chemotherapy agents has changed the treatment plan for many oncology patients. Oral cancer therapies have many patient benefits, including greater flexibility and convenience with minimal disruption of activities of daily living. Reports suggest that oral oncolytic medications account for approximately 25% of the current oncology treatments. The National Institutes of Health reports that adherence to this treatment can be impacted by a variety of factors. The World Health Organization defines related factors that can impede adherence as patient, condition, therapy, social/economic, and healthcare team/system. As these therapies become more widely prescribed, cancer programs and education around these therapies need to adjust to this new and developing landscape. This includes identifying best practices and the barriers that delay the process from prescribing to adherence and compliance. As nurse navigators are tasked with providing education, along with continued monitoring, this poses a significant challenge, especially when it is unclear when a drug is prescribed and when the actual delivery of the medication took place. A literature search did not indicate national benchmarks related to delivery time; however, studies indicate that many barriers impact the process. These process delays can cause significant time delays, financial constraints, and frustration, which in turn decrease the patient’s adherence and start time for oral chemotherapy treatment.
Objective: As a quality initiative, HonorHealth Virginia G. Piper Cancer Care Network (VGPCCN) examined the oral chemotherapy workflow and identified the leading barrier as “system related.” VGPCCN found a significant gap in standardization and oral chemotherapy coordination. As a result, the VGPCCN navigation program was identified as the key change agent as navigation is recognized for highly coordinated care and ability to identify and eliminate barriers. It was tasked with developing standardization practices across the VGPCCN.
Methods: The navigation team along with oncology service leadership built a new navigation team called oral chemotherapy navigators (OCN). The primary focus of the OCN is to coordinate care from the point of prescription to delivery. Workflows include prescription review; investigation of benefits; routing script to appropriate pharmacy; financial assistance; and communication with nurse navigators to begin oral chemotherapy education and update them on the process of receiving the medication related to timeline, finance, and start of therapy. In addition, the OCN communicates with the patient regarding fill process, and the OCN documents in the medical record with a specially designed “oral chemotherapy note”; this note is available by providers and other clinicians to allow transparency on the process of medication procurement and any potential delays.
Results: The OCN and new standardized workflows were put in place in March 2018, and to date continue to show a significant decrease in re-scribe numbers and time of pharmacy dispense. In May, a total of 623 prescriptions were reviewed; 31% were antineoplastic and prescribed to a specialty pharmacy. Mean time to dispense was 10.37 hours. Subjective findings by navigation staff also noted increased patient satisfaction with the additional coordination and communication, and a decrease in financial cost to the patient due to early financial aid started and insurance authorization.
Conclusions: The OCN plays an essential role in the oral chemotherapy process. Integrating this new role into navigation can improve timeliness of care, multidisciplinary communication, patient education, and monitoring for adherence and compliance.
SourcesRaborn ML, Pelletier EM, Smith DB, Reyes CM. Patient out-of-pocket payments for oral oncolytics: results from a 2009 US claims data analysis. http://ascopubs.org/doi/full/10.1200/jop.2011.000516.
Schneider SM, Hess K, Gosselin T. Interventions to promote adherence with oral agents. Semin Oncol Nurs. 2011;27:133-141.