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High-Quality Care in Multi-Site Networks: Implementing a Centralized Pharmacy and Pathways

Publication: Journal of Clinical Pathways

In a presentation at the American Society of Clinical Oncology (ASCO) Quality Care Symposium (September 6, 2019; San Diego, CA), Lalan Wilfong, M.D., vice president of value-based care programs, Texas Oncology, chaired a session on building high-quality cancer care across multi-site networks. Journal of Clinical Pathways discussed with Dr. Wilfong some of the strategies to ensuring high-quality care that Texas Oncology has utilized.

Earlier today, you helped facilitate a session on building high‑quality cancer care across multi‑site networks. If you had to narrow it down, what would you say is the most important component of a multi-site network that successfully implements high-quality care?
Dr. Wilfong: First, identifying what exactly you mean by high‑value care and high‑quality care as a practice. Defining exactly what you are trying to achieve is the first and foremost important step. From there, practices should strive to recognize the variations that you have to make to implement the quality initiatives in different programs.
Within Texas Oncology, we have 210 sites of service. One site has 50 physicians that are all sub‑specialists. Contrarily, some rural locations employ only one or two physicians, and these physicians treat a very different patient population compared with those the metropolitan area.
Identifying what initiative we are trying to achieve and then recognizing the variations that we have to do to achieve that initiative in that population is the underpinning of everything we do to ensure that we are delivering care in a multi‑site network.
What are some of the universal challenges that large networks face when implementing high‑quality care, and what are a few of the challenges specific to Texas Oncology?
Dr. Wilfong: Access is an important issue for many of the initiatives. A “high‑quality care team,” including social workers, pharmacists, nurses, physicians, other resources, works really well in certain places but not as well in other regional variations.
For example, in a rural area, there may not be any social workers that live within 200 miles of a treatment site. How do we then incorporate technology to ensure that those patients have the same access to those services as places within the Texas Oncology network that have access to more resources?
Technology can solve a lot of problems that we have with access. Reporting metrics are key in this space because it allows physicians to report on the quality of work that they undertake. Having the technology to support them is helpful in achieving quality initiatives.
What are some of the strategies that Texas Oncology uses to achieve high‑quality care across the network?
Dr. Wilfong: One of the problems we recognized early on was full access to specialty drugs, particularly in regard to different centers with varying access. Some of our large centers may have three or four pharmacists working in that center, and one of those pharmacists may have the time to talk with patients about their drugs. Other centers may not have that same level of support.
Thus, we decided to centralize our pharmacy to allow for one intake for all oral prescriptions. We have one team that is tasked with patient assistance and education, so there is now one unified place where sub-experts are delivering high‑quality care for all patients that we see.
The pharmacy team that work in our oral clinics have experts in knowing exactly what financial resources are available to help patients with out‑of‑pocket copays. They know the resources are available for our patients, as well as handle prior authorization requests.
They have that expertise to understand the steps needed get drugs approved by the payers. Centralizing that process has been very helpful and successful for our patients.
How has aligning the care team within your medically integrated pharmacy led to both internal as well as patient satisfaction?
Dr. Wilfong: Staff‑wide prior authorization has been huge because our physicians are not burdened with prior authorizations.
Additionally, all staff members in our network have access to the same EHR. Our pharmacy team knows exactly what the physicians want when they prescribe a certain drug. They complement the education that is being given. Every step of the way in our process between the physician, the advanced practice providers, the nursing staff, and the pharmacists, staff members can easily see what steps have occurred and fill in the gaps.
Everyone can work together to ensure that patients are put through all of the necessary steps to receive the proper drugs. For example, our pharmacists can see patients’ lab values in real time. If they recognize that a dose adjustment is needed, they can contact the physicians in real time to make those adjustments. The same relationship holds true if a physician was to contact a pharmacist in our network. Dose adjustments are very common in oncology.
We have seen with outside pharmacies that when prescribing a patient a drug, they are often obtaining refills without getting proper dose adjustments. It can lead to a lot of complications.
By having an integrated team in real time, we are able to make those adjustments consistently. Everybody on the team is aware of the adjustments needed. It is truly a unified approach; there is no confusion between our pharmacists, nurses, advanced practice providers, and physicians as the optimal care of our patients.
When you go through the process of designing, evaluating, and maintaining your clinical pathways, do you receive more negative feedback from physicians or payers when you formally remove a drug from a pathway in favor of another drug?
Dr. Wilfong: As the chair of the Pathways Task Force for US Oncology, I’ve led the efforts in our pathways program to make the process very transparent for all of our physicians. Physicians know in advance what data and research the Task Force plans to examine for pathway consideration. They have freedom to comment on those data.
After the Task Force votes on specific drugs, the results are shared in our network with our disease‑specific committees, which then have the opportunity to comment on the decisions made. Then, everything is shared with the entire physician group for final comment before Task Force review and implementation.
To summarize this process, the Task Force votes on a regimen, but then we make sure we have buy‑in from the disease‑specific committees and within the general medical oncologists before we implement pathways changes.
Within our pathways program, we follow an 80/20 rule: 80% of treatment should be on‑pathway, while 20% should not. All of our practices have processes where they look at that exception process. Physicians are encouraged to prescribe drugs that are off‑pathway for patients if the patient and the physician believe that there is a potential benefit.
Most of these decisions are reviewed by a group to ensure that appropriate care is being administered. Most of the time, when physicians treat off‑pathway, it is for a very justifiable reason. We have gotten a strong sense of buy‑in from our physicians about pathway implementation and the 80/20 rule.
As far as payers go, most are following NCCN guidelines and we are concordant with NCCN. All of our pathways regimens are on NCCN guidelines because we have an already-established partnership with NCCN. Therefore, payers know what they are getting into when they contract with us, and there is not much pushback from them.

Read the full story at Journal of Clinical Pathways.

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