Positive Practice Changes After the COVID-19 Pandemic: From the Advanced Practice Provider Perspective.

At the opening session of JADPRO Live Virtual 2021, panelists shared creative responses to the COVID-19 pandemic and considered strategies to effectively respond to crises that may impact cancer patients and practices in the future.

The COVID-19 pandemic may have changed some aspects of health care forever. At JADPRO Live Virtual 2021, a panel discussion focused on how several cancer centers faced challenges, and what changes the participants view as positive. JADPRO Live is an annual educational conference for advanced practitioners in oncology.

The discussion was summed up by moderator R. Donald Harvey, PharmD, BCOP, FCCP, FHOPA, Professor and Director of the Phase I Clinical Trials Program at the Winship Cancer Institute of Emory University, Atlanta, and Conference Chair of JADPRO Live 2021: “Let's cement some of the positive changes that have happened to affect deeper change in the future, should another pandemic come.”

‘FLEXING’ AND ‘PIVOTING’

Memorial Sloan Kettering staff saw opportunities to “flex” and “pivot” to adapt and meet the immediate challenges of the pandemic, according to Aaron Begue, MS, RN, NP-C, Vice President for Advanced Practice Providers at Memorial Sloan Kettering Cancer Center, New York. Staff adapted their current skill sets and developed new ones to care for patients with COVID-19. This was facilitated by gathering in “daily huddles,” he said, to better understand the day's challenges and to disseminate new information. “That led to our building teams of APPs [advanced practice providers].”

One of their key actions was to devise staffing schedules for 12-week rotations, during which staff members altered between critical care responsibilities and their “home team.” The aim was to avoid burnout from the stress inherent in critical care. “That was a huge lift and a testament to the commitment of our APPs—to be willing to rotate in and out, caring for our patients with COVID,” Mr. Begue said.

Another significant change was to allow the patient intake process to occur remotely. Working from home, staff could perform such tasks as obtain the medication list, review morning lab results, identify problems areas, and initiate any follow-up for those issues, he explained.

TRIAGE: AN IMPORTANT PROCESS

Caleb Raine, PA-C, oncology physician assistant in the Bone Marrow Transplant Service at Winship Cancer Institute of Emory University, said his group at the COVID clinic developed a “strict triage system” by which they communicated closely with satellite campuses. They developed a patient assessment algorithm, which facilitated communication among all parties. “Getting those key words that may suggest an infection, and maybe rerouting the patient to the appropriate clinic, can help keep COVID spread down…In the future, I’d like to see that strict triage process continue,” he said.

Dr. Harvey commented that these examples represent very positive consequences for oncology settings: “Despite the devastation caused by this pandemic, these concepts of improved communication, improved processes, and more partnerships are things I hope we can continue to leverage throughout all practice areas and all aspects of research and patient care.”

PANDEMIC EXACERBATED THE DISPARITIES

As an epidemiologist, Robin Yabroff, PhD, MBA, Scientific Vice President for Health Services Research at the American Cancer Society, was very interested in how the pandemic might affect the receipt of cancer services, including screening, evaluation of signs and symptoms, diagnosis, and treatment. Not surprisingly, she said that the pandemic, which caused not only disruptions in employment and health-care delivery, but individual economic losses, exacerbated disparities already existing in the United States (Yabroff et al., 2021).

“We immediately started looking for real-time data in early March 2020,” she said. She and her team began by exploring opportunities with the leaders of the Surveillance, Epidemiology, and End Results (SEER) cancer registries from Georgia and Louisiana. They learned that electronic pathology reports are generated in real time after every cancer diagnosis and treatment, and thus provide a good indication of the care being received. Comparing data from 2019 and 2020, they observed large declines in electronic pathology reports starting April 2020 and continuing to the end of that year, with these drops bigger in some months than others.

“Of note, these declines in reports during 2020 coincided with increases in COVID mortality rates in Georgia and Louisiana,” she said. Overall, by the end of 2020, pathology reports had declined by 10% compared with 2019. Declines in reports were observed for cancers with effective screening tests, like breast and colorectal cancers, as well as other cancers. Declines in the numbers of reports were highest among older patients, but the reports also declined by nearly 40% for children and adolescents; this suggested to Dr. Yabroff problems with the delivery of many essential health-care services for the younger age group as well. In her ongoing research, she is exploring geographic variations in how cancer was being treated during the pandemic. Preliminary results show COVID-19 “hot spots” demonstrated bigger and steeper declines in cancer treatments, again reflecting a pattern of health-care resource restraints.

According to Dr. Harvey, this “heightened noise” of the pandemic has changed an “already vulnerable population” to one even more vulnerable in terms of cancer screening and detection.

One positive trend, Dr. Yabroff added, is that providers have become more likely to inquire about a patient's insurance coverage, employment status, housing instability, food insecurity, transportation barriers, and other potential challenges to receiving care. “My hope is that there will be greater attention to identifying and addressing those barriers to care going forward,” she said.

TELEMEDICINE: PROBLEMS TO OVERCOME

Telemedicine became an essential part of patient care during the pandemic, but as panelists pointed out, logistical and administrative issues have caused headaches. There are multiple technologic platforms, broadband weaknesses, problems with patients’ connections and equipment, and even a “chip shortage” that made acquisition of computers for remote staffing challenging at times. However, according to Mr. Begue, the biggest hurdle yet to be addressed pertains to state licensure requirements that made it impossible for providers to practice consistently across states.

Dr. Harvey further noted that telemedicine can bring its own staffing challenge, as more dedicated personnel may be needed; this could potentiate disparities in care. “I personally buy into telemedicine, so to speak, but certainly understand the limitations and wonder whether we will just be creating a bigger divide in terms of rural populations, poverty, broadband, etc.”

MANAGING STRESS AND BURNOUT

Job stress and burnout were being felt in oncology long before the pandemic. “The pandemic only elevated the importance in addressing them,” said Dr. Harvey. The panelists described how their own institutions tried to ameliorate job stress and burnout.

Mr. Begue said his institution, Memorial Sloan Kettering, which employs more than 900 APPs, puts stress and burnout “constantly at the forefront of what we want to address and work with.” During the lockdown, the cancer center was allowed to use school outdoor play spaces as staff respite areas. And the center's psychiatry and behavioral health team “decided on its own accord,” he said, to offer individual and group counseling in the evenings. “Those kinds of grassroots initiatives really helped keep things going, but we have to keep innovating in this area because burnout's not going away anytime soon,” he added.

Support from the wider community clearly lifted spirits in the early days. “In New York, the crowds coming out at 7:00 PM every night to cheer us, whether it was an orchestra, band coming up the street, fire department…was the community coming together,” Mr. Begue said. “Now, seeing how long this pandemic has continued, it's more challenging.”

The Emory neighborhood also rallied around its health-care workers, placing encouraging signs around the campus and even donating money for meals and snacks several times a week. “People came together, and that was very inspiring to me…I’d be driving home, maybe after a really bad day, and see signs on the road. That actually helped,” Mr. Raine said.

Mr. Raine added that Emory's Spiritual Health Team was also there for the oncology team, offering telehealth visits for staff who wanted to talk or vent frustrations. “I saw people break down because they felt bad just going home to their families, not knowing if they contracted COVID. I think Emory did well in addressing psychological health.”

‘PERSONALIZE’ THE WORKPLACE

The pandemic has offered more job flexibility for many—remote work, less rigid schedules, shifting responsibilities. This has been met with eager acceptance by many oncology providers.

Mr. Begue advocates now for team members to enjoy enough flexibility in their workspace that their needs are better met. For instance, he said, “being with the patient when it's most critical, and for work that is not necessarily ‘patient-facing,’ doing some of that in a place and at a time that is more convenient” to that staffer are useful approaches.

“I would like to see the opportunity that exists in our outpatient telemedicine be blended with what could be delivered in the inpatient world. We need to expand our thinking and get creative…That's the only way we are going get through burnout and have the ability to adapt to change over time,” he said.

Dr. Harvey agreed and used a familiar term in oncology; the concept of “personalized care,” he said, should expand to include the personalization of the workplace as well.

CLINICAL TRIALS: SOME POSITIVE, SOME NEGATIVE CHANGES

Finally, the panelists applauded what they hope is the beginning of greater flexibility within the clinical trials system. Although study enrollment has suffered, for multiple reasons, some aspects of the process became easier during the pandemic.

At Memorial Sloan Kettering, for example, telemedicine made it possible to enroll patients and obtain signed consents remotely, and APPs played a large role in this process. In fact, because of their more substantial involvement, many have become co-principal investigators, Mr. Begue said.

Mr. Begue believes that some relaxing of state licensure requirements could result in greater participation in trials, as coordinators could reach more potential patients via televisits, and centers could more easily collaborate. He would expect, he said, “bigger numbers than what we’ve done in the past” and a more “efficient virtual collaborative research model,” which could expand the trials’ reach. One payoff could be the ability to tap into those parts of the country that have been historically underserved in the trials process.

Simpler clinical trial protocols would also greatly help, added Dr. Harvey. “This would mean not mandating that patients return on so many days just for observation or things that are not necessary…It would reduce bureaucracy and allow for a more straightforward process for everyone,” he added. With job shortages from the pandemic also affecting the research setting, “we have to build our research staff back up and then think differently about how we employ and work through these issues in the future.”