The “New Normal”: Seven Questions Program Leaders Are Asking About Care Amid COVID-19

By Deirdre Saulet of the Advisory Board

Note: This article was originally published on May 13, 2020 by the Advisory Board on Oncology Rounds

Welcome to "Field Report," a new series where Advisory Board experts weigh in on what they are hearing from health care organizations across the county. In this edition, Deirdre Saulet shares findings from recent networking forums with cancer program leaders across the country on what their "new normal" looks like.  

What are cancer program leaders' top priorities?

As health care systems begin to resume services, cancer programs face a new crop of issues—from restarting cancer screenings to implementing semi-permanent "socially distant" operational changes.

To facilitate collaboration and idea sharing between oncology leaders across the country, the Oncology Roundtable held two networking forums last week. Here are the top questions cancer program leaders raised and the solutions they offered to address each of them.

1. Are you testing cancer patients for Covid-19? If so, how?
2. What happens if a patient tests positive?
3. How are you managing employees' return to work?
4. Are you starting to relax "no visitor" policies?
5. What longer-term changes are you making to infusion center operations?
6. When and how are you resuming cancer screenings?
7. How are you delivering an exceptional patient experience under the current circumstances?

1. Are you testing cancer patients for Covid-19? If so, how?

Given the shortage of tests and lack of national-level guidance, it's not surprising that testing processes and protocols came out as top area of discussion—and, unfortunately, ambiguity. Many organizations are working with physicians and care teams to develop screening algorithms and policies, especially for asymptomatic patients. 

Ochsner Health, which has facilities in and around New Orleans, serves an area hit hard by the country's Covid-19 epidemic and has focused on offering widespread testing to its patients and community. The health system's oncology service line tests patients on infusion therapy every two weeks, at least 72 hours prior to their appointment. It also tests patients receiving radiation therapy once per course of treatment. (Of note is that Ochsner's radiation oncologists have all embraced hypofractionation so that most patients complete treatment within three weeks.)

Because it often takes 24 hours to receive the Covid-19 test results, Ochsner also offers rapid testing, which delivers results within 15 minutes, to patients who live more than 50 miles from the facility and to urgent add-on infusion patients. And it has started offering in-home testing, contracting with the company Ready Responders to perform swabs at patients' homes and deliver them to its lab for cancer patients who can't get to a drive-thru site or qualify for home health services due to risk of exposure. Ochsner's overall testing process has been implemented across all sites and physicians, with some exceptions due to complicating patient factors, such as head and neck cancer patients.

Other health systems routinely screen patients for Covid-19 only at the start of cancer treatment, or, if access to tests and the associated supplies are limited, organizations will only screen patients receiving specific procedures and treatments, such as all surgery patients and those on acutely immunosuppressive chemotherapy.

You can also check out UAB Medicine's asymptomatic testing strategy, which appeared on the National Comprehensive Cancer Network's Covid-19 resource page.

2. What happens if a patient tests positive?

When patients are symptomatic and Covid-19-positive, most organizations are postponing treatment, especially chemotherapy that significantly harms the immune system. When a patient is symptom-free for 14 days and has two negative tests 24 hours apart, he or she can resume treatment.

However, patients are often asymptomatic and can test positive for as long as 60 days. At that point, it might not be feasible to wait to treat their cancer. Decisions to start or resume cancer treatment for these patients are typically made on a case-by-case basis. Cancer programs have implemented protocols for treating these Covid-19-positive patients.  

To maintain separation between Covid-19-positive and negative patients, organizations have creatively repurposed underutilized space, such as a dermatology clinic or wig shop, to serve as a negative pressure infusion room specifically for Covid-19-positive patients. Many reserve the end of the day for scheduling Covid-19-positive radiation patients to minimize exposure and allow for full disinfecting of the multifunctional linear accelerators (LINAC) and facility afterwards. 

3. How are you managing employees' return to work?

At the end of April, CDC updated its return-to-work criteria for health care providers with suspected or confirmed cases of Covid-19. For the symptom-based strategy, employees should not return to work until three days following resolution of symptoms and 10 days following the first appearance of symptoms. However, the stakes are higher when working with an immunocompromised patient population, so many cancer programs are lengthening that criteria and requiring that employees have between seven and 14 symptom-free days before to returning to work.

Importantly, at organizations using widespread employee antibody testing, leaders emphasized the value of communicating to their team members that the presence of antibodies doesn't mean they're risk free or can't be infected again, and to continue using proper personal safety precautions.

4. Are you starting to relax “no visitor” policies?

While many health systems are starting to loosen their visitor policies by allowing one visitor per patient, cancer programs are mostly sticking to the no-visitor policy. The key to success here is clearly communicating the policy and the reasoning behind it to patients.

Some centers allow an exception to the no-visitor policy by permitting one visitor for initial consults, which tend to be overwhelming and full of crucial information. The organization keeps a list of approved visitors at the entrance to ensure adherence to the no-visitor policy for all other appointments.

5. What longer-term changes are you making to infusion center operations?

While many infusion centers are spacious enough to maintain a minimum of six feet of distance between patients, organizations are trying new strategies to further improve physical distancing. Some of those include:

• Setting strict maximum occupancy levels: Infusion center leadership at one organization collaborated with physicians and nurses to determine appropriate occupancy levels for staff and patients in the infusion center and ways to optimize space with fewer chairs in use, based on the facility's physical layout and workflows.
• Improving scheduling: A recurring theme of infusion center efficiency—even before the pandemic—is evening out appointment scheduling. Infusion center volumes tend to peak across the morning into mid-day, so there's an opportunity to better utilize afternoons. Some organizations are improving their scheduling templates by using their EHR or infusion-specific scheduling software, like iQueue. A few leaders noted iQueue's infusion recovery calculator provides a good way to estimate your backlog of deferred treatments and how much capacity you'll need to free up to accommodate those volumes moving forward. It is worth nothing that, due to financial and productivity pressures, most organizations hadn't added evening or extended hours yet, but they also haven't written off the possibility that they'll need to add those eventually.
• Keeping patients for as little time as possible: This approach may include working with pharmacists to adjust the dosing and length of infusions. Additionally, there tends to be a lot of opportunity to improve the efficiency of injection-only visits, where patients can be separated and "fast-tracked" by a dedicated provider, spaced out during the day, or moved to an on-body injector if they're receiving Neulasta.

Find out what 55 cancer programs told us about how they were treating patients—and keeping them safe—during Covid-19.

6. When and how are you resuming cancer screenings?

Organizations are eager to get cancer screenings back up and running to minimize the number of late-stage diagnoses and poor outcomes. In fact, most organizations are starting up screening earlier than anticipated—some at the beginning of May. There seemed to be an even split between organizations starting with lung cancer screening and then phasing in mammography, and vice versa. To make this phase-in period work, here are the tactics organizations are using:

• Screening before the screening: Staff call patients in advance of their appointments to ask about Covid-19 symptoms, remind them to bring their masks, and inform them of their new protocols. They take the patient's temperature upon arrival, just like all other entrants.
• Getting rid of the waiting room: Patients wait in their cars before their appointments, and staff call or text them when they can enter the facility to reduce the time they spend waiting inside.
• Scheduling more time in between appointments: To reduce wait times and build in enough time for sterilization and cleaning, radiology departments are scheduling appointments every 30 minutes, rather than every 15 minutes as previously done.
• Communicating with patients: When screenings start back up, it is critically important to make sure people feel safe and comfortable coming back into the hospital or screening facility. One program did a "soft" launch for mammography where they reached out to all scheduled patients in advance—and every patient who was contacted ended up coming in for their exam.

Screenings may come back online fairly quickly—or slowly—depending on a number of factors, such as when referring providers ramp back up, how comfortable your patients are, and how hard Covid-19 hit your area. It will be critically important for cancer program leaders to watch these volumes, along with surgical cases, and prepare for a downstream surge in diagnoses, which may require making the case to your leadership for bringing furloughed staff back.  

7. How are you delivering an exceptional patient experience under the current circumstances?

At the core of every cancer program's mission is delivering an exceptional patient experience. And many of the elements that are considered critical to patient-centered care are no longer being offered, such as massage, fitness classes, and Reiki therapy.

While those types of services have been discontinued, likely for many more months, programs are making the most of virtual care to continue providing support groups, palliative care consults, social work, genetic counseling, and frequent navigation touches. One tactic an organization is using to celebrate the end of treatment involves navigators recording patients' stories and their bell-ringing ceremonies to send to patients as keepsakes, in addition to videoconferencing their family and friends.