Balancing Inpatient and Outpatient Oncology Care

Presented by:
Rachel McDevitt
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 PharmD, BCOP
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John McLean
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 MBA
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Mikaela Olsen
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 DNP, APRN-CNS
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Beth Souza
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Moderated by:
Anna Halpern
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 MD
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The trend of moving oncology care to the outpatient setting is driven by clinical and patient-centered aspects, financial benefits, and the lack of inpatient bed space. At the NCCN 2024 Annual Conference, a panel of experts discussed challenges and opportunities in providing high-quality outpatient oncology care, including resource allocation, leadership recognition, and involving all stakeholders in the decision-making process. Speakers also highlighted the difficulties in providing adequate outpatient cancer care, such as limited lodging options, adapting treatment for elderly patients, and managing infection risk. Strategies for improving patient satisfaction, reducing costs, and enhancing quality of care centered on proactive risk assessment, standardization of policies and procedures, and creative solutions such as curbside clinics.

The migration of oncology care outward from traditional inpatient settings has become an inevitability in the field—and one that is underpinned by a complex interplay of forces. Financial drivers play a large part, with institutions grappling with the economics of health care delivery. However, patient preference and the optimization of clinical outcomes remain paramount.

In a recent panel discussion at the NCCN 2024 Annual Conference, experts explored the pressures, challenges, and innovations involved in transitioning oncology care from inpatient to outpatient settings. The panel included Rachel McDevitt, PharmD, BCOP, Oncology Pharmacist at the University of Michigan; John McLean, MBA, Associate Vice President of Managed Care Contracting at the University of Pennsylvania Health System Abramson Cancer Center; Mikaela Olsen, DNP, APRN-CNS, Clinical Program Director at Johns Hopkins Health System; and Beth Souza, Executive Director at Mass General Cancer Center; and was moderated by Anna Halpern, MD, Associate Professor at the University of Washington and the Fred Hutchinson Cancer Center—all of whom brought diverse insights to the discussion around this transformative shift.

Pressures and Institutional Responses to Change

A combination of clinical, financial, and patient-centered considerations is compelling oncology care toward outpatient settings. Ms. Souza emphasized the importance of assessing where patients can receive optimal care. This question gained newfound urgency in light of the COVID-19 pandemic, which acted as a catalyst for accelerated change. The discussion also shed light on bed shortages and heightened risks within hospitals, further tipping the balance toward outpatient services.

“Prior to the pandemic, [but] especially since then, inpatient bed space has been a big issue, and I’m sure we all feel the crunch on that,” said Dr. McDevitt. “So, we’re trying to move [more care] to the outpatient setting. And a lot of patients really prefer it; for example, our pediatric patients with sarcoma who are getting high-dose methotrexate.”

The panelists shared a consensus on the COVID-19 pandemic’s role as a turning point, which, despite being a global health catastrophe, necessitated and expedited the move toward more agile and patient-preferable care methodologies (such as drive-up curbside clinics for hormone therapies and chemotherapies).

Institutions such as Johns Hopkins have responded to the outpatient care mandate with innovations in clinical operations, Dr. Olsen noted. Central to these responses is the intricate balance of resource allocation—maximizing the efficient use of inpatient facilities while scaling up outpatient capacities. The panelists also discussed the crucial role of managed-care contracting, site-of-care policies, and understanding payer dynamics as instrumental in this transition.

“Patients who want to be in their own homes deserve that if it’s possible,” Dr. Olsen said. “And being in the hospital, we know patients are at risk for hospital-acquired infections. So to me, that’s one of the important drivers.”

Benefits, Challenges, and Special Considerations

The transition to outpatient care comes with substantial benefits, such as increased patient comfort, decreased risk of hospital-acquired complications (eg, nosocomial infections), and better use of health care resources. However, according to Ms. Souza, one of the biggest pressures driving the shift is capacity constraints.

“Inpatient capacity is at a maximum, and ambulatory capacity for us is also pretty high,” she said. “So, I would say capacity is creating this need, but we have to figure out how we are going to deliver the best care to patients, with the best possible outcome and in the best possible location. How are we going to continue to adapt to where patients would like to get their care, as well as where it’s safe to give care in the most effective and economical way?”

The dialogue highlighted the necessity of redesigning workflows to accommodate lengthy treatments within the restrictive hours of outpatient clinics while ensuring robust support systems are in place to manage the continuity of care outside hospital settings.

Geographic diversity also imposes unique challenges in the transition to outpatient care. Dr. Halpern discussed innovative solutions to support patients who travel long distances for care. Reduced-cost lodging and partnerships with local accommodations are among the solutions being explored to ensure that the shift to outpatient care does not disproportionately disadvantage those from remote or under-resourced areas.

Amid this change in infrastructure, patient needs are, above all, pivotal in shaping care protocols. According to Ms. Souza, this involves a comprehensive approach considering the patient’s clinical, psychosocial, and financial circumstances.

Infrastructure, particularly in terms of staffing, education, and physical resources, is foundational to a successful outpatient care model. It necessitates strong support from leadership and an all-encompassing strategy that spans the breadth of patient care.

Financial, Leadership, and Supportive Care Considerations

Shifting the site of care affects reimbursement and the economic burden on patients. As the panelists noted, outpatient care may reduce costs for insurance companies but could simultaneously transfer costs to patients through copays and associated nonmedical expenses. Navigating these financial implications requires careful planning and communication with payers and patients alike.

“We get better margins in providing [some of our CAR-T therapies] in the outpatient setting,” said Mr. McLean. “It takes a team to have the infrastructure to follow the patient, but it’s still much, much less expensive than doing it in the inpatient setting.” He added that generally speaking, outpatient care is less costly to the insurance companies, so payers are—for the most part—on board.

Supportive care is another integral component of outpatient treatment. Dr. McDevitt highlighted time-saving measures such as oral medication alternatives and educational initiatives. These measures empower patients and caregivers to manage care at home, thereby conserving precious resources such as infusion center space and reducing patient visits. Providing caregivers with resources for at-home care is a testament to the comprehensive nature of outpatient services.

The panel agreed that having dedicated leaders—who understand the necessity of appropriate resources—is crucial in steering the transition toward outpatient care. A council or task force that encompasses diverse stakeholders, including executive leaders, clinicians, and patients, is essential for overseeing this transition. It provides a platform for strategic planning, allocating resources, and integrating best practices.

“Also, although it’s been painful and I didn’t always like it, I do believe that doing a proactive risk assessment, where you get all the stakeholders involved and map out the process and look at failure modes, is critical to this transition process,” noted Dr. Olsen.

Actionable Strategies for Implementation

To successfully implement outpatient oncology services, the panelists recommended creating multidisciplinary teams, ensuring proper resource allocation, and integrating patient and caregiver feedback into care models. Building on established best practices and using modules, templates, and processes such as those from NCCN may provide a structured pathway for implementation. Such an approach ensures that transitions to outpatient care are not only clinically sound but also tailored to the needs and preferences of patients.

“One thing we’ve done at our center that has been helpful since the pandemic is implementing an oncology-specific urgent care,” said Dr. Halpern. “It closes around 10:00 PM, but radiology saves imaging spots for [these providers], they have access to a rapid blood bank supply, and a large bank of intravenous antibiotics. This way, they’re able to keep many patients out of the emergency room. Unfortunately, we can’t save beds for patients, even though we know they’re often going to come back.”

With patient care at its core, the evolution toward outpatient services is poised to reshape the landscape of oncology, promising more personalized, flexible, and efficient treatment options for patients.

Ms. Souza concluded, “A successful transition is about leveraging the talent and expertise that we all have in our cancer centers, with our multidisciplinary teams of [advance practice providers], physicians, nurses, and administrators, to think about an approach that actually is beneficial for patients, in a way that makes sense.”

Disclosures: Dr. Olsen has disclosed receiving honoraria from BD; and serving as a consultant for BD. Dr. Halpern has disclosed receiving grant/research support from Bayer HealthCare, Disc Medicine, Gilead Sciences, Inc., Incyte Corporation, Jazz Pharmaceuticals, Karyopharm Therapeutics, Merck & Co., Inc., PharmEssentia USA, and Protagonist Therapeutics Inc.; serving as a consultant for AbbVie, Inc., Karyopharm Therapeutics, and Notable Labs; receiving trial funding from PharmEssentia USA; and receiving honoraria from Curio Sciences. The remaining presenters have disclosed no relevant financial relationships.

Correspondence: JNCCN Editorial Office, 3025 Chemical Road, Plymouth Meeting, PA 19462. Email: JNCCN@NCCN.org
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