Anti-Cancer Therapy Privileging for APPs — [PODCAST] EP 93

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For more than a decade, the United States healthcare system has been warned of an impending oncologist shortage that is projected to occur as the population continues to age and the demand for cancer services increases. As integral members of the cancer care team, advanced practice providers (APPS) play a pivotal role in the rapidly evolving oncology ecosystem, bolstering access to quality care. Allowing APPs (e.g., nurse practitioners and physician assistants) the privilege to sign anti-cancer treatment orders not only improves access to high-quality cancer care, it can also free up physician time to see more new patients and streamline clinic workflow.

Guest:

Archana Ajmera, MSN, ANP-BC, AOCNP

Advance Practice Provider Supervisor

University of California San Diego Moores Cancer Center

“APPs are able to fill that area of practice for symptom management and for urgent triage issues… Our APPs are really able to jump in at those moments [to] provide urgent visits within 24 hours [or] within 7 days post-discharge to be able to provide higher quality care.”

Resources:

• A Virtual Summit to Define the Role of Oncology Advanced Practitioners in Equitable Cancer Care Delivery: Executive Summary
• [MINI-PODCAST] Ep 63: Advanced Practitioners’ Role in Research
• [MINI-PODCAST] Ep 65: Integrating Advanced Practitioners into Research
• An APP-Physician Model Improves Risk Stratification and Palliative Care
• Expediting Cancer Treatment Through a Rapid Access APP-Led Diagnostic Clinic
• Filling the Gap: APP Utilization to Meet Care Needs in Oncology
  

Transcript

CANCER BUZZ: Welcome back to CANCER BUZZ. I'm your host Summer Johnson. Today, the growing role of oncology advanced practice providers or APPs. Some cancer programs allow APPs to practice independently through a collaborative care approach. For many APPs, practicing at the top of their license means having the ability to sign anti-cancer therapy orders. APP privileging allows physicians to see more patients, it streamlines clinic workflows, and improves the patient experience, but implementing a process for APPs to receive this type of privileging takes a bit of effort.

Archana Ajmera is a Nurse Practitioner and the APP Supervisor at the Moores Cancer Center at the university of California, San Diego.

Archana Ajmera, MSN, ANP-BC, AOCNP: You know, in my career, I've seen the movement and the shift towards more independent practice, because really, you know, people are realizing all that we can do, especially in cancer care. And I think there's not as many oncology providers and so they do need more people and you know, more providers to be seeing these patients that are seeking care. So, I have seen the evolution from kind of much more of a shared model in the last five years to a much more independent model and starting to see kind of the value that APPs bring to the practices.

CANCER BUZZ: What have you seen as the impact on the patient when APP is able to work closely with them independently?

Archana Ajmera, MSN, ANP-BC, AOCNP: Yeah, I think that that's a great question. And this is something that we're all working hard to try to measure in a tangible way, but some of the initiatives that are underway now, particularly at our institution is we're looking at re-admission rates, which is huge. APPs are able to fill that area of practice for symptom management, for urgent triage issues, so I really do think post-discharge, you know, sort of acute post-discharge planning and coordination and it's not just coordination of care, but it's did you get your meds?

Did they stop your anti-cancer therapy when you were in house for this unrelated issue? You know, and so our APPs are really able to jump in, in those moments, provide sort of urgent visits, you know, within 24 hours within, seven days post discharge—to really be able to provide higher quality care in the sense that we can see people quickly, you know, we have availability and then it also frees up for the oncologist to be able to see more new patients.

So the APPs can see follow-ups, they can do symptom management, they can urgently triage patients. And, of course, we're always collaborating with our physician colleagues, but it just creates more space for patients.

CANCER BUZZ: What are the changes that you were working for at UCSD?

Archana Ajmera, MSN, ANP-BC, AOCNP: You know, when I came to UCSD Cancer Center, our APPs were not signing anti-neoplastic therapies and that's specifically the IV therapies. We were able to however, renew oral anti-cancer therapies. There were some clinical trials that we were able to sign prescriptions for. So, it just seemed a little discordant with kind of what the standard practice was for oral therapies. And so, it was an initiative I took on along with my physician collaborator, Rana McKay, MD, and we did our research and tried to identify what other institutions were doing, tried to see what protocols were in place.

You know, there were obviously, you know, it was a big practice change. And so now what our APPs are able to do, and this is dependent on the team that they're in the experience that they have, but they're able to sign both oral and anti-neoplastic therapies IV therapies. Additionally, with the changes at the NCI, they've recently approved for advanced practice providers also to be signing some of the clinical trial drugs. And so, this kind of came right after my policy went into place.

About a year later, the NCI changed their policy with clinical trials. And so now our APPs can sign, ALLIANCE Study, you know, drugs and things like that. So, it's really made a big difference. It's not across the board that all the APPs in HemOnc are doing this it's really disease team specific. And it's a collaborative kind of decision with the APP and the physician.

CANCER BUZZ: Besides your physician collaborator, did you have to get some sort of administrative buy-in and how did that go?

Archana Ajmera, MSN, ANP-BC, AOCNP: Yeah, so that was quite a big lift. It probably took us about 10 months all in all. So, you know, we put together a protocol, we vetted it with, you know, key stakeholders. So, we vetted it with kind of some of the oncologists in the practice. We vetted it with our pharmacy. And then we went through a series of committees actually at the hospital level. So, we went through our pharmacy and therapeutics committee. We went through our nursing executive committee. We went through our physician committee; we went through med staff credentialing committee.

So, there were multiple layers of key stakeholders that really needed to buy in. And, you know, we made modifications along the way, but the reality is that this wasn't something coming out of nowhere. Right. We had modeled it after many other institutions…Stanford, UCSF, the Dana-Farber, Mass General... I mean, a lot of these institutions were already doing this. And so it wasn't, you know, it wasn't kind of created from scratch.

CANCER BUZZ: Was that the thing that got you over the hurdle for stakeholder buy-in was the fact that it was being modeled elsewhere.

Archana Ajmera, MSN, ANP-BC, AOCNP: So, I think one thing is that there was actual experience that we could speak to both myself and the attending. The second thing is that there's clearly protocols in place at other institutions that we're able to share. And then three kind of the realization that our APPs are really strong, you know, and they're doing this every day and they're doing it, whether they're with you in clinic or not with you in clinic, and they're very comfortable managing toxicities, they're very comfortable understanding the chemotherapies and how we adjust doses and you know, what we need to hold for. So, I think, you know, definitely multifaceted in that regard.

CANCER BUZZ: What do you think is the biggest challenge to moving an organization to APP privileging?

Archana Ajmera, MSN, ANP-BC, AOCNP: So, one of the things I think was the biggest challenge in building the protocol is understanding what defines competency. Okay. So, you know, I, as APP, sure, I've been in practice for 10 years, but how do you know that my skill level is the same as another APP who's been in practice for 10 years? And you know, what we wrote out in the protocol was that we wanted the APPs to have the ONS chemotherapy biotherapy certification course, or, you know, greater than three years of experience as a clinician in oncology.

Now, I feel like maybe we could do better in that regard. Maybe we could have an APP specific course, maybe some APP specific material that is a required certification if you've never been in practice before. And the reason I say that is, you know, I think the ONS chemo-biotherapy course is excellent, but I do think it doesn't have necessarily the provider level information that's needed.

CANCER BUZZ: If you'd like to learn more about what we discussed today, head to the link in the show notes. or you can check out the latest edition of Oncology Issues. That's online or in your mailbox next week on CANCER BUZZ, addressing sexual health during cancer treatment until then this is Summer Johnson.

CANCER BUZZ: CANCER BUZZ is a resource of the Association of Community Cancer Centers (ACCC).