Cancer Care In Transition

When patients with cancer leave the hospital, they’re usually overwhelmed with multiple items demanding their attention. Chief among them is filling their outpatient prescriptions, according to Nelly G. Adel, PharmD, BCOP, BCPS, chair of pharmacy practice and associate professor of oncology at Touro College of Pharmacy in New York, New York.

Community pharmacists play an important role in helping oncology patients manage their prescriptions. First and foremost, because these patients often take many medications, it’s important to have a medication expert review them for appropriateness. “Pharmacists can review medication lists to ensure that prescribed regimens are cost-effective, safe, efficacious, and being used for the proper indication,” said Roxane L. Took, PharmD, BCACP, clinical pharmacist at Gateway Apothecary in St Louis, Missouri, and assistant professor of pharmacy practice at St Louis College of Pharmacy at University of Health Sciences and Pharmacy in St. Louis. Although other health care providers are capable of fulfilling these roles, research has shown that pharmacist-provided services can reduce physician visits, emergency department visits, hospital stays, and overall health care costs.¹

Another reason why community pharmacists are in a prime position to assist transitions of care for patients with cancer is because they’re the most accessible health care providers to the public. “Patients can call or walk in to see them without an appointment and receive professional medical advice about their medications or get referrals to appropriate higher levels of care if needed,” said Roman Fazylov, PharmD, BCPS, clinical pharmacist for internal medicine and assistant professor of pharmacy practice at Touro College of Pharmacy.

When patients with cancer have questions about treatment plans or a medication’s adverse effects (AEs), community pharmacists are well-equipped to offer 1-on-1, in-person counseling. In addition, these patients may try self-care practices, such as taking vitamins, minerals, and herbal supplements. “While some of these may help certain ailments, some also have serious risks,” Fazylov said.“Pharmacists can advise patients on self-care strategies that are effective and carry a low risk of adverse [effects].”

Community pharmacists also can provide access to hard-to-find medications, and they work with physicians and insurance companies to provide expedited drug coverage and access to novel therapies, said Kavel Bhathela, PharmD, a community pharmacist at Carolina Pharmacy in Charlotte, North Carolina. They can offer medication delivery as well as medical and household supplies needed for managing disease, making it convenient for transitioning patients. Furthermore, pharmacists can collaborate with other health care providers and monitor and optimize drug therapy for complex disease states.

Here’s a closer look at the specific roles community pharmacists can play in transitions of care for patients with cancer.

Medication Reconciliation

Before a patient even leaves the hospital, community-based specialty pharmacists work with the discharge team to reconcile all prescribed medications, troubleshoot prior authorizations for prescriptions, and enroll patients in copay assistance programs, said Vivianne K. Celario, PharmD, a registered community-based specialty pharmacy manager at Walgreens in New Brunswick, New Jersey. Additionally, pharmacists conduct initial consultations with patients to assess their understanding of therapy goals and potential AEs. Patients are enrolled in the pharmacy’s clinical care program, where pharmacists monitor their treatment, adherence, and AEs, and address barriers that may arise between hospital and clinic visits.

It is important for community-based specialty pharmacists to work with the discharge team to establish that any medications a patient took prior to admission, including OTC medications and supplements, continue to be safe and effective with a patient’s newly discharged medication list, Celario said. For example, newly prescribed oncology medications often have the potential for drug interactions and AEs. Pharmacists can perform drug utilization reviews and address the need for dose changes or recommend drugs to alleviate AEs to increase treatment efficacy and adherence.

Due to a rise in the use of oral and self-administered oncology prescriptions, the success of a treatment greatly depends upon the patient, which is why it’s important for patients to understand their therapy goals and potential AEs.

Community pharmacists also can review patients’ OTC and prescription medications to improve patient safety and adherence. Carolina Pharmacy offers medication strip packaging and medication synchronization services, which help patients keep up with taking all of their medications on time and appropriately. “Through these services, we can check and see how patients are doing, and address any questions or concerns they may have regarding their drug therapy and overall well-being, which helps to builds trust and strong relationships with patients,” Bhathela said.

Educational Initiatives

Community-based specialty pharmacists receive advanced training specific to oncology to effectively educate patients about their medications and the challenges they may face during their cancer journey, Celario said. These pharmacists can perform initial patient consultations, reassessments, and cycle dosing education to monitor patient adherence. In addition to onsite counseling tools, pharmacists work with manufacturers and professional and patient cancer organizations to provide patients with medication education kits, seminars, workshops, and advocacy support.

Due to the complexity of cancer treatments, a patient’s list of prescribed medications can be extensive. Consequently, multiple drug therapies are quite common. Known as polypharmacy, this can become problematic if patients end up with medications they don’t need, Adel said. Therefore, it’s essential for pharmacists to carefully review these patients’ medication lists and counsel them accordingly.

Managing Pain and Comorbidities

Comorbidities are common among patients with cancer. In addition to cardiovascular conditions and diabetes, these patients may experience mental health conditions and chronic pain. This leads to patients taking multiple prescriptions and visiting multiple providers. “Community pharmacists are essential in maintaining a patient’s most accurate drug profile, as well as bridging any communication gaps between the patient, hospital discharge team, cancer care team, and the specialists and primary care prescribers patients see,” Celario said. “Furthermore, due to their accessibility, pharmacists are great resources to assist patients in managing chronic conditions and [adverse] effects that come with having cancer and getting treatment.”

Fazylov said that pharmacists also can play roles in managing insomnia, changes in bowel habits, decreases in appetite, and other comorbidities. “Many of these issues can be managed with over-the-counter therapies,” he said. Pharmacists are trained to monitor pain medications by keeping track of total dose requirements and monitoring AEs. In turn, they can make recommendations to prescribers regarding the right dose and frequency of pain medications to help optimize pain control while keeping AEs at bay.

Other Areas of Expertise

Many oncology medications are costly; community pharmacists can address any cost issues that patients may have. Pharmacists can relay concerns to the appropriate physician, and suggest cost-effective alternatives.

Community pharmacists also can provide delivery services through a “meds-to-beds” program in which the pharmacy brings a patient’s medications to them before hospital discharge. “These programs help identify and resolve barriers to adherence sooner than a typical community workflow process,” Took said. “By identifying medications that cannot be filled due to formulary restrictions or medication cost, this program also helps to decrease readmission rates.”²

Getting Started

Resources are available to assist pharmacists who are looking to implement a transitions of care program. For example, the American Pharmacists Association’s Transitions of Care Toolkit was developed to help pharmacists implement or enhance their transitions of care programs in order to improve patient care, reduce health care costs, and optimize medication therapy, Took said.

Took would also encourage community pharmacies to initiate a pilot transitions of care program with patients recently discharged from the hospital, and to offer it free of charge initially. During this early phase, pharmacists can identify common characteristics of patients who are discharged, a patient populations’ needs, and a hospital’s receptiveness to working with them.

To take the program a step further, Took would advise pharmacists to work with a local hospital near their pharmacy and engage with management to develop a proposal to present to hospital leadership.

As pharmacists go through the process, they should have realistic expectations.

“Although it’s ideal to follow up with patients within 48 hours of discharge, it may not be ideal for your pharmacy’s workflow,” Took said. “You may find that it’s best to limit your service to a certain patient population, such as those aged 65 and older or patients with diabetes.”

Lastly, don’t be afraid to outsource a service or even partner with another pharmacy such as a specialty pharmacy, Bhathela said. The more services and access to care and products you provide, the more your community will rely on you for their health care needs.