Three Ways to Address BMT Patients in Community

Liam Davenport

February 26, 2019

HOUSTON — Providing ongoing care in community settings to patients who have undergone blood and marrow transplants (BMTs) is a challenge.

However, three nurse-led studies, presented here at the Transplantation & Cellular Therapy meeting, showed how this circumstance can be tackled in a variety of ingenious ways.

Christina Ferraro, MSN, Taussig Cancer Institute, Cleveland Clinic, Ohio, and colleagues devised a nurse practitioner-run BMT survivorship clinic for patients who had undergone allogeneic hematopoietic cell transplant (HCT).

Testing it in more than 160 patients, they found patients underwent required tests and screens at the 100-day post-transplant and 1-year follow-ups, with a high rate of adherence.

Jennifer Barrett, BSN, Blood and Marrow Transplant Program, Seattle Cancer Care Alliance (SCCA), Seattle, Washington, and colleagues took a different tack, holding a summit with community nurses to identify challenges with handing over patients from hospital care.

After developing a standardized and easy-to-use discharge process, they were able to more than double the rate of handoffs to community nurses to 80%, informing them of the patient's imminent arrival more than a week beforehand.

For patients living huge distances from the institution, the challenge of providing follow-up care is even greater, however.

To help the diagnosis and monitoring of patients who develop graft versus host disease (GVHD) when back in community care, Claudine Schneider, BSN, RN, also of the SCCA, and colleagues established a telemedicine program.

Educating patients on how to capture diagnostic information on camera and then securely email the photos, they have been able to follow up with patients in far flung corners of the United States, seeing more than 30 patients every week and fielding dozens of calls.

Nurse Practitioner-Run Clinic

Ferraro began her presentation on the nurse practitioner-run clinic by noting that the estimated number of survivors of HCT is set to rise from approximately 110,000 in 2009 to around half a million by 2030.

Survivors face a number of issues following their transplant, including an increased risk of cardiovascular, pulmonary, hepatobiliary, and pulmonary disease, alongside GVHD, infections, and second cancers.

The 2012 recommended screening and preventive practices for long-term HCT survivors set out a number of guidelines for how patients should be followed up.

These include blood tests, immunizations beginning 6 months post-transplant, echocardiography or electrocardiograms in high-risk individuals, and eye and dental exams, among others.

In response, Ferraro and colleagues developed their survivorship clinic in partnership with specialties such as gynecology, ophthalmology, and rheumatology, as well as social workers, clinical nurse coordinators, pharmacists, and schedulers.

Following their transplant, patients were then scheduled to see a nurse practitioner and social worker at day 100 post-transplant, and at 1 year, 2 years, and 5 years.

The visits consist of a comprehensive history, physical and symptom assessments — including questionnaires, blood panels, bone marrow biopsy, and pulmonary function tests — and a GVHD evaluation.

The patients are then given a care plan that includes screening, vaccine, lifestyle recommendations, educational materials, and primary care provider identification.

Ferraro told the audience that the assessment can take from around 20 minutes to up to two hours, depending on the complexity of the case.

Between 2016 and 2018, 161 patients underwent allogeneic HCT, with 131 patients seen at day 100 post-transplant and 42 at 1 year.

Patients were not seen at day 100 due to relapse, death, or an acute illness making them unable to attend the clinic.

Among patients seen at day 100 but not at 1 year, seven were abroad, two had relapse, 12 had died, one had transferred their care, and 67 had not yet reached their 1-year follow-up at the time of analysis.

Looking at the 42 patients seen at 1 year, the researchers found that all had received their treatment summary and care plans, and 35 saw their social worker.

In addition, all patients completed their blood and pulmonary function tests, and 41 had their bone density assessed. In addition, 36 patients had an eye examination.

Thirty five patients were recommended colon cancer screening, of whom 20 had undergone a colonoscopy at 1 year.

All 20 women seen at 1 year had received a mammogram and 19 had visited with a gynecologist.

In closing her presentation, Ferraro said: "We have a lot of things we're planning and hopefully we'll be able to implement in the future."

She explained that they will start integrating patient-reported outcomes and conduct "interventional research on late effects to improve the well-being of long-term sufferers."

Community Nurse Summit

Barrett told Medscape Medical News that the SCCA performs almost 500 BMT transplants every year.

The majority of patients return to community oncology practices for ongoing care, and their long-term follow-up (LTFU) department currently supports more than 6000 BMT survivors in the community.

Barrett explained that, while the LTFU is more informal than the survivorship clinic described by Ferraro, it provides patients with online resources and ongoing telephone support once they have left SCCA care.

She said that "it is a comfort for patients, because it's kind of like their extended warranty of their transplant."

However, to improve the transfer of patients to community care, the LTFU sponsored a summit for community nurses in 2017, during which the challenges faced by nurses when caring for BMT survivors were discussed.

Two of the major difficulties were inconsistent nurse-to-nurse handoff when transferring patients and the late notification of discharge, which left nurses unaware of the imminent return of a patient to community practice.

To standardize the BMT patient handoff, the LTFU team evaluated the community nurse feedback and examined nursing workflows for adult allogeneic and autologous transplant discharges.

They created a user-friendly standardized discharge form and obtained community nurse contact information, with the goal of submitting discharge materials more than 5 to 7 business days ahead of the patient's first post-transplant community visit.

After implementation, the researchers examined discharge data and conducted community nurse surveys from July 2018 to December 2018 to determine the impact of the changes.

Before the implementation of the new handoff procedures, 33% of community nurses reported that they received a nursing handoff from the SCCA before the patient returned to the community.

Following implementation, that figure rose to 80%, with 100% of community nurses who received the handoff saying that it improved patient care.

Barrett said that, while it was "a little difficult" to get some of their nurses onboard for the project, it provided an opportunity to network with the community nurses and get to know them, which she found "very rewarding."

She said: "It was really nice to have that connection, and I think it also eased some of the stress."

She added: "These are very complex patients that you're sending back to the community, and bigger facilities, academic centers, tend to forget that they're a well-oiled machine."

For community nurses, "it is kind of scary to get all these patients, and these nurses are not only dealing with transplant patients, they're dealing with all oncology patients," she said.

Next, the LTFU will hold another Summit in May 2019, where Barrett said they are "going to continue to network and bridge that care [with the community] and hopefully, in the long run, improve our BMT survivors' care."

However, achieving that connection with patients in the community can be difficult when they live long distances from the larger healthcare institution.

Telemedicine Solution in Vast Western US

To get around that problem, Schneider and colleagues from the SCCA developed what they believe could be the first telemedicine long-term follow-up program for BMT survivors in the United States.

The need arose because the SCCA treats patients in Washington, Alaska, Idaho, and Montana, as well as further afield, making it impossible for some patients to return easily if they have any issues.

Schneider told Medscape Medical News that patients may also "come to us from other institutions, especially if they've gotten a transplant somewhere else and maybe it didn't work, or maybe they're looking for a clinical trial that maybe we're doing that another place is not."

As patients can have complex needs following BMT, particularly if they develop chronic GVHD, and because the majority of care is provided in the community after the first 100 days post-transplant, they devised a comprehensive photography program.

To provide a reliable tool for the diagnosis and assessment of therapy response for patients with GVHD, patients and providers alike were educated on how to use photography to capture key diagnostic features.

Specifically, the patients were provided with detailed instructions on how to photograph skin, range of motion, and the oral cavity.

To establish a baseline, LTFU clinic nurses took medical photos prior to BMT discharge to establish a baseline, after which patients or community providers could securely email photos to the clinic.

These were then reviewed by a telemedicine team and compared to previously taken images.

While the SCCA has approximately 6000 active patients, Schneider said that they actually have more patients but are no longer having active GVHD issues or have accommodated them.

She said that, every week, the telemedicine group currently consults with an average of 33 patients and receives around 60 calls from patients and their community providers, including both adult and pediatric patients.

For the future, the team are exploring the possibility of using videography and live-streaming for physical assessments and integrating mobile health apps to make the service more patient-centered.

The authors have disclosed no relevant financial relationships.

TCT 2019. Presented February 23. Abstract 102, Poster 643, Poster 647

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