TIPS AND TRICKSTroubleshooting the Set Up of the Clinic for Advanced Prostate Cancer Patients

Moderator: Neal D. Shore, MD, FACSPanel Discussion

2

Barriers to Establishing APCC

Design

Lack of leadership Lack of involvementLack of awarenessLack of importance to physiciansConflicting guidelinesMixed attitudes of how to practiceTime constraintsResourcesIncreased costs

Implementation

Lack of outcome expectancyPractice inertiaConvincing physicians of importance of APCCPossible loss of patientsCost effectivenessResourcesLack of belief

Evaluation

Time constraintsOversight of operationLack of feedback from those involved

3

What Makes a Champion? ●Embraces role as a patient advocate to ensure initiation and completion of treatment ● Proactively prepares patients for treatment process ● Builds a partnership with Nurse Educators ● Works with clinical staff to develop a consistent plan for patient identification

●Dedicated to the treatment of advanced prostate cancer●Have intellectual and clinical desire to follow various treatment modalities

●Fully understands the practice economics of APCC● Seize the pro forma business benefits ● Understands reimbursement of approved therapies ● Understands the infrastructure and cost required to implement APCC successfully.

4

Nursing Champions Impact Patients

• Successfully integrate treatments into clinical practice

• Educating patients and ensuring appropriate monitoring

PatientCare

Provider

Educator

PatientAdvocate

• Talk with patients about treatments (clarify and answer questions)

• Ensure patients have confidence

• Assist patients with obtaining therapies• Connect patients with resources and support

groups

5

IntegrationClinical Integration

• Developing sub-specialty expertise

o Clinical trialso Dispensing o Infusion o Injectiono Radiographic testingo Patient Visits

Business Integration

• Grow revenue • Expand market share• Champions:

Physician Nurse Administrative

• Culture: Leadership Management Followership

6

Capital Requirements for APCCStaffing Commitment from current staff, or Hire additional staffNurse navigator or manager for patient identification and education

Space consideration Maximize existing space Acquire new space

Equipment/Supplies Rent or lease Purchase

7

Operationalizing APCC: Balancing Business and Clinical Excellence

• Top obstacles for developing an APCC as it relates to reimbursement and billing:

– Cost of drugs

– Administering drugs not centralized

– Understanding profit margins

– Confidence in billing personnel

– Carriers to restrict who they allow the practices to treat (preauthorization)

8

Operationalizing APCC: Balancing Business and Clinical Excellence

• Top obstacles for developing an APCC as it relates to identifying patients:

– Physician concerns – addition of staff

– Physicians correctly coding

– Sub-specialty expertise to treat advanced prostate cancer patients

– Need for pathways for appropriate patient identification

– No financial incentive for physicians

– All decision making currently on physician

9

Financial Commitment to Develop APCC Clinic

• Infusion/Sipuleucel T – Moderate Capital expense

• Injection/Radium 223– Moderate/plus capital expense

• Dispensing prescription/Enzalutamide and Abiraterone– Moderate/plus capital expense

• Denosumab, Docetaxel, Cabazitaxel, and growth factors. – Moderate/plus capital expense

10

Change Your Outlook: Systematize/Standardize

Reward behavior What gets measured, gets done.

Share and

share – alike

Here, there, and everywhere Right people, right seats

11

Benefits of APCC Provides an ability to expand your

clinic and sustain: Higher quality of care and improved

patient outcomes

Retain patients and gain additional

consults

Grow revenue and market share

Promote center of excellence

12

Take-Home MessageInvest time and effort in identifying physician

champion, nurse champion, and administrative

champion.

Integration and sub-specialization is crucial for

the establishment of APCC.

TIPS AND TRICKSLeanne Schimke MSN, FNP-C, CUNP

14

Identification of symptoms• Evaluation of activity level can help identify

symptoms• What are they doing for activity or exercise?• Can identify need for analgesics, further

interventions• For example:

– George is an avid golfer, plays 18 holes twice weekly. Comes in to see you and states he is only playing 9 holes once a week. Question to ask is “Why only 9 holes now?”

15

Fall evaluation• Do a fall evaluation with each visit.• Have they fallen over the last 6-12 months? • What was the cause of the fall?• Did they have any injury?• Counsel on how to avoid falls• Do they need some physical therapy?• Do they need to be on a bisphosphonate or

denosumab?• Have they had a DXA bone density study?

16

Assessment of Pain• Have spouse or significant other present

during visits• Ask if they are having any pain or

weakness.• Men do not like to admit they are having

pain and often it is the spouse or significant other that will tell you about it.

17

ADT Clinic

• Start seeing men when they are started on ADT• If feasible, have a dedicated day to do injections

with consistent staff members• Builds relationship• Gives them someone they can feel comfortable

addressing their concerns to.• Helps with early identification of CRPC• Evaluate chart at each visit for progression