Managing Patients With CLL in the COVID Era: The Advanced Practitioner's Role

Lisa Nodzon: Welcome to this virtual roundtable, Managing Patients With CLL in the COVID Era: The Advanced Practitioner's Role. My name is Lisa Nodzon. I'm a nurse practitioner in the Department of Malignant Hematology at Moffitt Cancer Center in Tampa, Florida. Joining me today are my two colleagues, Jackie and Katie.

Jackie Broadway-Duren: Hello, everyone. My name is Jackie Broadway-Duren, and I am a nurse practitioner in the Department of Leukemia at MD Anderson Cancer Center. Nice to be here with you today.

Katie Tobin: Hi, everyone. My name is Katie Tobin, and I'm a clinical pharmacist in malignant hematology at Moffitt Cancer Center in Tampa, Florida.

Lisa Nodzon: In our first installment, we will focus on current data regarding COVID-related diagnostic delays and how this has affected the CLL patient population, particularly at our respective cancer centers. Several lines of published data have shown that around 41% of the U.S. population have reported having delayed or avoided medical care due to the COVID pandemic. While there has been a decline in new cancer diagnosis, not specific to CLL, since the pandemic start, there was no reason to believe that the actual incidence has decreased.

At Moffitt Cancer Center, we had to shift our care delivery model to ensure both patient as well as staff safety, as our patients are amongst the most vulnerable for morbidity as well as mortality from COVID-19 infections. We employed such strategies in the beginning as only allowing the patient to attend the clinic visit, which, as we can see, made some visits difficult, particularly for our more frail patients, as well as those that are poor historians. As well, we had to relocate certain staff members to work at offsite work locations, which presented communication challenges. We had COVID screening for all staff, as well as patients and any visitors at all of our entrances. We had COVID testing performed before all chemotherapy and surgery or any aerosol generating procedures, which did require a lot of care coordination, and some of our patients do drive quite a distance to our center.

As well, we had to do the coordination of a lot of outside labs with the patient's physician's outside laboratories, as well as, in hematology, we do require labs prior to our patient visits, so that was quite challenging. And basically we had to convert to telemedicine overnight, so not only was it a learning experience for us staff, it was quite a learning experience for our patients as well and did present a challenge as not all of our patients are amenable for telemedicine visits. As well as when the COVID-19 vaccinations were rolled out, that required a lot of collaboration amongst the different clinics, as well as our patients, particularly if they were on active therapy or traveling quite a distance to collaborate that care.

In terms of clinical trials, I would say that we really didn't halt for a very long period of time, so not enough to say that we had a significant impact at our center. Jackie, so is the data on the care transition that we saw at Moffitt Cancer Center consistent with what you were seeing at MD Anderson Cancer Center?

Jackie Broadway-Duren: Yeah, I'd say this is very consistent. We're experiencing exactly the same challenges. I think one of the greatest challenges—well, there were several, but first of all, patients, in spite of the fact that they're already stressed out regarding treatments and visits, as Lisa said, most of them are coming from out-of-state, so they're worried about getting there. Many of them are driving, where they normally would fly, for 12 and 13 hours to get there. Then the screening process, it was quite traumatic for many of them to have loved ones not be able to come in with them into the clinic, and so, yeah, those were all challenges. Telehealth was definitely a challenge because many, as she stated, were unable to use the equipment we had. In our clinics, there were times we weren't able to log on right at the moment that we had scheduled a video visit.

So as far as clinical trials, I would say for the most part, they continued on because our wonderful, lovely pharmacies were able to jump right in there and find alternative methods of getting those medications shipped to the patients to try for continuity of care. So yes, it was pretty much some of the same that Lisa mentioned in our facility.

Lisa Nodzon: Yeah, so it was definitely a learning experience for all of us overnight, and some good things and some bad things have come out of that. Well, the impact on cancer patient management has been such that the NCCN has set forth some recommendations to ensure, encourage, and facilitate cancer care coordination so that our patients are being seen timely without delay. Most importantly, maintaining their cancer screenings as well as resuming evidence-based care. So Katie, have you seen an impact on any of our infusion-based treatment delays, or from your pharmacist perspective has there been any impact on the ability to fill patients' medications, or even, most importantly, provide medication safety teaching?

Katie Tobin: Yeah, so I've really not seen a huge impact on infusion-based treatment in terms of authorization, but there have been some restrictions on who can accompany the patient to the ambulatory infusion appointment, so that can lead to delays in scheduling just because of the patient's comfort level. Now, overall, we've not seen a ton of delays in getting medications filled, but early on in the pandemic, there were delivery delays, so luckily that has resolved since the beginning. Now, the ability to provide patient safety teaching has been impacted. When the transition started, pharmacists were one of the first team members, at least at Moffitt, that had to go transition to work from home, so this really limited our ability to have in-person teaching with our patients in the clinic, as well as an infusion center. So at Moffitt, the infusion center pharmacist also provides counseling prior to Cycle 1 infusions, and this had to just stop overnight.

Now, specialty pharmacy luckily could continue to call patients and counsel over the phone for any new oral medications. I do think with time clinical pharmacies, staff, we did really well to adapt and provide counseling over the phone as we worked from home. This did help bridge the gap for medication safety counseling, but it was still difficult for older patient population, which really includes a lot of our CLL patients. In-person teaching is normally more effective and preferred, so I definitely do think it's added some stress and work onto our providers and nurses in clinic.

Lisa Nodzon: Yeah, I definitely think even for the lack of our ability to have our pharmacists go in and teach with our patients, and even as staff, we had felt it was difficult. We're so accustomed to having our pharmacists in clinic to be able to help us with medication safety, so it was definitely an impact on staff as well, as you mentioned, so we know our pharmacists play an incredibly important role, not only with our patients, but also with our staff.

Well, now that we've resumed in-person care more regularly with allowance of a healthy visitor to accompany our patients at Moffitt Cancer Center, we know we're busier in terms of capacity, as well as workload, to ensure not just our patient but our staff safety as well. Some of the good things that have come out of it is we have developed a curbside administration of certain injectables for patients that are amenable for that. We also have expedited rooming of our patients to avoid overcrowding in our waiting rooms, as well as we've seen an increased volume of patients at our center that are relocated from other centers out-of-state that are brand new to the state of Florida. Unfortunately, we have had some staff shortages due to COVID-19 infections or COVID exposures, particularly early on in the pandemic when we were sorting our way through things prior to the vaccination. As well, we're seeing some longer clinic schedules in our patients because in the interim, they have not been able to see their other specialty providers, perhaps for diabetes or hypertension, or even with primary care, the patients haven't been able to make it out there, so we've had to kind of address some of those things in the interim. So Jackie, how is the effort to return to inpatient care going at MD Anderson?

Jackie Broadway-Duren: Well, it has presented some challenges. One of the main ones being that most family members still are not able to accompany the patients to their appointments, particularly in the older population who already have problems with needing assistance, and some more emotionally than physical. As a result, we had longer visit times trying to communicate with family by phone or having to get an interpreter where that family member normally would've interpreted for the patient. It has definitely created more of a workload on the APPs, because as you stated at the beginning of this, all of our whole entire research nurse population was transitioned to work from home; so therefore, we are in there in lieu of them and had to obtain many of the informed consents and it's just the increase of the workload for us, but overall we've adjusted and just do whatever you have to do to make sure that the patients get what's needed. One thing I might add that the pharmacies started before the COVID-era shut down, they started a telephone telehealth program where they talk with the patients and check in with them at home once they started new oral agents. So that was something they were able to continue. So, we don't have the luxury of having enough pharmacists to do in-person visits with the patients, that kind of falls to the APPs and the physicians.

Lisa Nodzon: Yeah, it was definitely a learning curve for a lot of us overnight, and I think we're still having the impact of these busier workloads as we try to care for our patients and kind of still fulfill their needs with some of the ancillary services that kind of went by the wayside with our patient population. Katie, how do you think pharmacists have transitioned during this time? As for a brief period, you mentioned earlier, they were working remotely through telemedicine, which represented challenges not only for our patients but for our staff.

Katie Tobin: Yeah, so, like I said, it was difficult to adapt quickly to the new workflow, and I think pharmacists in general, but especially at Moffitt, we did our best not to add new workload to the new staff. And similar to Jackie, what you had just said, pharmacists at Moffitt adopted that practice, so I think working from home gave us the ability to reach more patients in the long run. We have the flexibility to call patients either using the Doximity app or our own personal phones throughout the day, and from my point of view, I really felt like I was able to reach more patients and that's a practice that now we've adopted in our clinic practice. It is still a challenge though for our older patients trying to set up Zoom appointments, or getting phone calls and going through the education over the phone, it's still more difficult rather than being in person. The providers also did a lot of Zoom clinic appointments, and we've also adopted this practice to try to continue to offer counseling and patient education in that manner.

Lisa Nodzon: Yeah, so we've seen that the COVID-19 pandemic has led to several very meaningful implications for our practice. Some of the good things: we have paved the way for improved access for some of our patients through telemedicine, as one example; however, we do have a paucity of oncology patient care delivery. Well, the impact may not immediately be known but could have some forthcoming implications in the future based on the delay of care for some of our patients.

One of the important things that we have learned through the pandemic, as well with our patients is we have to remain vigilant with our patients, in particularly with their screening processes, where things were delayed. We have to continue to encourage timely follow-up visits as well with our providers; not just with us, but with our other patient specialties as well. Perhaps they've missed cardiology visits or endocrinology visits as well in the interim, or because some of our patients have even missed their routine screening colonoscopies that are also really important. As we know, they're higher risk for these secondary malignancies, medication compliance as well, and that's where Katie, as you mentioned, pharmacists really play a huge role with us in talking to our patients about the safety of the medications as well as compliance, especially for the new oral oncolytic starts.

We have to still continue to encourage self-care as well as self-monitoring. Our patients play a really active role in their care, but also engaging their family members as well too now that we have resumed this more in-person care. Most importantly, I think we have to continue the collaboration that we do have with our community oncologists as well as their patients' other specialists as well, as it really does take a village to manage our malignant hematology patients, and importantly, making sure that our patients are getting the continuity of care that they need as well as the cancer screening set forth and recommended by the NCCN guidelines.

So that brings us to the end of the case. Please see the other segments for further discussion about the implications of the COVID-19 pandemic on patients with CLL, or visit advancedpractitioner.com. Thank you.