Oncology Pharmacy Navigator: A Novel Model for Medication Management Kelly Rice, Pharm.D. Oncology Pharmacy Navigator Legacy Cancer Institute Portland, Oregon
Objectives Understand the role of an oncology pharmacy navigator in a system cancer program Name two cost saving programs that support the expense of an oncology pharmacy navigator position Give examples of reasons cancer patients use marijuana and cite one barrier to access. No disclosures May 1, 2017 2
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Identification of Need The vast majority of anticancer treatment is given outpatient, but Legacy Health had no oncology pharmacist dedicated to its outpatient clients. Upwards of 50% of patients do not take their medications correctly Med discrepencies, adverse events, and non-compliance are leading causes of 30 day hospital readmissions Cancer patients are highly satisfied when able to consult with pharmacist. Consultation allows patients and providers to focus on management of their cancer Novel model in the community, state, and nation. Best Practice Model according to ACS surrveyors. May 1, 2017 4
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Timeline February 2014: Development of proposal for new position, research done April 2014: proposal presented to Legacy Cancer Institute (LCI) medical and administrative directors. Endorsed November 2014: LGS Foundation Grant Requested for one year pilot position. February 2015: LCI granted funds for 0.4FTE position for one year August 2015: First quarter pilot results presented to LCI administration, increased to 0.5 FTE position April 2016: FTE position budgeted into LCI annual costs. May 1, 2017 6
Launch Office in LCI Healing Center, Bldg 3, lower level Very steep learning curve for outpatient EPIC as well as launching a new position (referral took 3 months!) EPIC outpatient training (4 hours) > Med Rec over the phone (must use orders only encounter) and for office visits > Creating current med lists and Frig Lists for patients over the phone and for office visits Pts can access via My Health (preferred email format) May 1, 2017 7
Your pharmacy navigator will help you: Understand your medications Provide a current and accurate medication list Understand the side effects of your medications & help manage the symptoms Make it easier to take your medications correctly through coaching, medicine schedules, and pillboxes Address medication related symptoms quickly Explore financial concerns related to your medicine May 1, 2017 8
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Fridge Med List: can be accessed from AVS or from an outpatient visit navigator May 1, 2017 11
Ambulatory Flowsheet Changes Add Needs Assessment: add Concerns re: Medication Adherence yes/no Add new section entitled Medication Concerns Medication reconciliation completed in EPIC: yes/no Med Rec # of meds on med list: enter a # Med Rec changes made: enter a # Med rec additions made: enter a # Med rec deletions made: enter a # Provided with epic med list: yes/no Provided with medication schedule: yes/no Assist patient with pill box: yes/no Med teaching provided: purpose of meds, timing of meds, and/or side effect management Health Literacy concerns: yes/no Medication adherence concerns: yes/no Patient on high risk medication (yes/no): If yes, choose one or several of these: anticoagulants, anticancer hormonal therapy, chronic opioids, oral chemotherapy, insulin, significant drug interaction potential Financial/Insurance concerns: yes/no Assist patient with smartphone app for adherence: yes/no May 1, 2017 12
Additional Services Provided: Chemo teaching for all LMG Gyn Onc chemo patients at LGS 6sw Bowel Protocol Quality Tracking Cancer support group presentations Attendance at two weekly huddles and GYN Cancer Conferences weekly May 1, 2017 13
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Estimated Cost Savings Annual Savings FY 2016: $208,242 Annual Savings FY 2017: $205,380 Examples of cost savings: $5000 Enroll oral chemo patient on foundation grant support $7800 Enroll patient in free Humira program $60,375 Enroll several patients on Lynparza Rx program $15,000 change from oral aprepitant to IV form on formulary $1300 Revenue from LGS Apothecary selling supplements $800 copay assistance for RadOnc pts Magic Mouthwash May 1, 2017 15
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Volumes & referrals May 1, 2017 17
Medication Reconciliation Over 110 patients had comprehensive medication reconciliation completed in Legacy EPIC system: Only 2% had entirely correct med lists Average Low High Meds on EPIC List 12 1 42 Meds Missing 1.8 0 10 Meds no longer Active 2.4 0 12 Meds needing Change 1.4 0 5 May 1, 2017 18
Quality metrics May 1, 2017 19
Future Plans Expand services to other Legacy sites via phone consult Conduct patient and provider satisfaction surveys Receive foundation grant funds to pay for supplements for some chemo patients Identify additional Pharma support programs Develop an Oral Chemotherapy Program at LCI May 1, 2017 20
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Oral Chemotherapy Program Patients need financial support in obtaining their medicines They also need experts to manage their medications. Team members will assist the provider in: > patient selection > perform insurance authorization, investigate and appeal all denied claims > improve access to medications > provide ongoing monitoring for adherence and side effects Provide patient specific medication therapy management, ensure that patients understand their medicines May 1, 2017 22
Medical Marijuana and Cancer Patients May 1, 2017 23
What do cancer patients ask for? Two main components of cannabis: THC and CBD Most dispensaries steer cancer patients towards products high in CBD. Symptom relief Nausea Appetite stimulation Pain Anxiety sleep depression menopausal sx Cure for their cancer: > Primarily RSO = Rick Simpson Oil May 1, 2017 24
Rick Simpson Oil (RSO) 85-88% THC Patients often referred to the Simpson Website = www.siskiyousungrown.com Comes only as a very concentrated solution in a syringe Only available to MM card holders, not recreational users Cost $30-50 per syringe, titrate up to one syringe/day. Discounts available, but still costs $700-$1000/month May 1, 2017 25
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What types of cannabis products are available? Bud/flower: for smoking or edibles > % THC & CBD shown Tinctures/concentrates in dropper bottles > Mg THC & CBD shown Vape cartridges/syringes shatter/sap strong hashish concentrate Gummies, lozenges, candy Topical salves, bath salts, lip balm Plants Sodas, drinks Other edibles = short shelf life May 1, 2017 27
https://public.health.oregon.gov/diseasesconditions/chronicdisease/ MedicalMarijuanaProgram/Pages/index.aspx May 1, 2017 28
OR Medical Marijuana Program (OMPP) Approved conditions: > Cancer > Glaucoma > HIV/AIDS > degenerative neurological condition > PTSD > Cachexia > severe pain or nausea > Seizures > persistent muscle spasms (ie MS) May 1, 2017 29
Why get a medical marijuana card? Card requires an MD or DO statement and costs $200 (reduced fees available) Cost savings (avoids 25% Oregon sales tax) higher quality product Can grow more plants Can buy more at a time and possess more Access to some products not available for rec users Need to use OMMP licensed dispensaries May 1, 2017 30
Common Questions about Cannabis Can I recommend it to my patients? How to choose a dispensary? Is cannabis organic? Are there excipients? Does topical cannabis cause blood levels? Is there research? www.researchcannabis.org www.cancer.gov/about-cancer/treatment/cam/hp/cannabis-pdq J Natl Compr Canc Netw 2016;14(7) 915-922. Cannabinoids for Sx Mgmt and Cancer Therapy: The Evidence May 1, 2017 31
Summary A need was identified, a position created and successfully funded for a pilot study and beyond 98% of medicine lists are inaccurate, and med rec done as outpatient is an important role of the OPN Financial savings projected at over $200K annually. Many cancer patients are interested in medical marijuana. We should be knowledgeable to answer their questions and outline the pros, cons, and logistics of accessing cannabis products. The OPN is an innovative role which distinguishes our cancer program, assists in accreditation, and most importantly benefits the cancer patients we serve. May 1, 2017 32
Thank you! Questions???? krice@lhs.org 503.413.6590