Smilow Cancer Hospital Town Hall | June 28, 2023

July 03, 2023

Information

Hosted by Eric Winer, MD, and Lori Pickens, MHA

Clinical Updates and Announcements

Kevin Billingsley, MD, MBA

Kim Slusser, RN, MSN

ASCO Medical Home

Michele Kelvey-Albert, MPH

Scott Huntington, MD, MPH, MSc

Medical Oncology Consult Transition

Elizabeth Prsic, MD

Oncology Drug Shortages and Smilow's Response

Eric Cabie, RPh

ID10097

To CiteDCA Citation Guide

00:00Agenda Today
00:07we'll be starting off with some
00:10clinical updates that Kim and I,
00:12as always, are pleased to share.
00:15Our Director, Doctor Weiner will
00:18be briefing our community about the
00:20very concerted efforts that our
00:22senior leaders both in the School
00:25of Medicine and in the Yale New
00:27Haven Health System are working on.
00:31To align the efforts of our partner
00:35organizations for improved patient care,
00:39service and financial performance,
00:42we have Michelle Kelvi,
00:44Albert and Doctor Scott Huntington who
00:46will be updating us on our ASCO Medical Home.
00:49We have some very exciting developments and
00:53our inpatient services that will involve
00:57the formation of a medical oncology.
00:59Consult team for inpatients, Dr.
01:03Liz Presage will be talking about that with
01:09additional input from Doctor Ann Chang.
01:12And as everyone in our community knows,
01:14we have been plagued with
01:17challenging oncology drugs shortages.
01:19This is not unique to our organization,
01:22but we have an incredible pharmacy
01:25team who's working on that and Eric
01:27KB has joined us this evening.
01:30To give us an update,
01:35Kim, I think I'll kick it
01:37over to you for the masks.
01:39All right. Thanks, Kevin.
01:42So welcome everyone.
01:43And this is a timely town hall,
01:46so we can just remind everyone
01:49of the updated masking policy.
01:51So as we know, a few months ago,
01:53we loosened up a lot of our restrictions,
01:56but beginning Saturday,
01:57the Saturday, July 1st.
01:59We are removing all masking
02:02requirements except for obviously
02:05isolation precautions when indicated
02:08for for all patient care and.
02:13And so that will be optional for patients,
02:15visitors and staff at Yale Medicine
02:17and Yale New Haven Health System.
02:19I do want to let our community
02:21know though that there are some
02:24ongoing conversations with our
02:25cellular therapy team and infection
02:27control to understand if there's
02:29anything different we should be
02:32doing and those environments.
02:34But but overall the the staff will
02:36mask when indicated and inpatient for
02:39isolation in the outpatient setting staff.
02:43A mask in rooms of patients
02:45with respiratory symptoms.
02:49We also wanted to take the time to
02:51congratulate our SMILO Cancer team
02:54at Saint Francis Medical Center for
02:57achieving their ASCO Kobe recertification.
03:00This is a wonderful accomplishment
03:01and as many of you know,
03:03the Kobe standards really focus on the safe.
03:09Safe practices and high quality care
03:11that we have around chemotherapy,
03:14ordering, prescribing,
03:16dispensing and administration.
03:18So a wonderful accomplishment and we
03:20want to congratulate our teams and
03:22thank you for all their hard work.
03:26We also like
03:26to take this time to.
03:28Announced new leadership positions and
03:30so we want to welcome Megan Berry,
03:34who many of you may know
03:35in the Smile community.
03:36She will be starting in mid-july
03:39as our Assistant Patient Services
03:41Manager for the Centers of Derby,
03:44Torrington and Waterbury for those sites.
03:47She started her oncology nursing
03:49career at Bridgeport Hospital on
03:51the oncology unit and she has been,
03:54she was an infusion nurse since
03:56Milo Trumbull and most recently
03:58she was the APSM for the medical
04:01oncology unit at Bridgeport Hospital.
04:02So she's returning to the ambulatory
04:05environment as an APSM and we're excited
04:08about her joining those locations.
04:11I'm going to turn it over to Kevin
04:12for a couple other announcements.
04:17So one of the things that is truly exciting
04:20in my role is to be able to announce
04:23the launch of new clinical programs.
04:26As many of you know Doctor A Hood
04:28or UDI Mendel has been on our
04:31neurosurgical faculty for over a year.
04:34We had the good fortune to recruit Dr.
04:37Mendel from Ohio State University of
04:40the James Cancer Institute where he.
04:43Developed a world class spine oncology
04:48program and he has launched that
04:50program now and we're taking that under
04:53Udi's leadership to the next level of
04:56multidisciplinary care and integration.
04:58And the Spylo Neuro Spine Tumor
05:01Board will be starting in July.
05:04Like all great clinical and
05:06research efforts in oncology,
05:08this is very much a team effort.
05:11Doctor Mendel's partner with this and in
05:14this effort primary partners Doctor on Yee,
05:19a radiation oncologist.
05:22There is also engagement from oncology,
05:26pain management,
05:27neuro radiology and of course
05:30medical oncology.
05:31And I think one of the things that
05:33is really exciting about this is that
05:35patients with a variety of tumors.
05:39Are vulnerable to metastatic
05:42disease in the spine,
05:45and this can be enormously
05:47debilitating in terms of pain,
05:49mobility and difficulties
05:52tolerating additional therapies.
05:54So this combined multidisciplinary approach.
05:58That is designed not only
05:59to keep patients functional,
06:00mobile and out of the hospital,
06:03but to keep them comfortable and pain free
06:04even in the setting of metastatic disease.
06:07So really exciting program
06:08and great to see this moving
06:10forward And I'd like to thank
06:13Doctor Mendel and colleagues for all
06:16of their hard work. Next slide please.
06:22Another thing that I'm really excited
06:24about is announcing the appointment of
06:27Doctor Scott Huntington is our Interim
06:29Chief Quality Officer for Spylo in
06:32the Cancer Hospital Cancer Center.
06:37Dr. Huntington probably needs very
06:39little introduction to this audience.
06:41He is an esteemed clinician.
06:43He's a leader in our lymphoma program.
06:46He wears a number of administrative
06:48hats already, including firm
06:49chief leadership on NP7.
06:52From chief leadership on NP11,
06:55Scott's a graduate of Mount Sinai.
06:57A resident at Vanderbilt did his fellowship
07:01at the University of Pennsylvania,
07:04where he also picked up a
07:06master's degree in health policy.
07:08So he is enormously qualified to be
07:11a leader and the quality space and
07:14we're really delighted that he's.
07:17Stepped into this role,
07:19as many of you know,
07:21Doctor Adelson did great work in this space.
07:25Happy to see her move on to other
07:28great things and just delighted
07:29that we have in our midst a really
07:32great group of leaders and happy
07:34to see Scott move into this role.
07:36Thank you, Scott.
07:38And you'll be featured soon
07:41on our program this evening.
07:43So I think Doctor Weiner. I think it's.
07:47I think you're next on that on the agenda.
07:51It's a deal. Hi everyone.
07:54So before I start I have to say that my
07:58colleague who used to be the chief of.
08:01Hematology and oncology at the
08:03University of Pennsylvania, and who
08:05Scott knew well when he was a fellowship,
08:08was in the fellowship there.
08:10Sent me a selfie of the two of
08:12them at ASCO and then had to add.
08:15Don't worry, I'm not recruiting him
08:18because she knew that if I thought
08:22she were that I would become.
08:25Just a little frustrated to say the least.
08:28But Scott, we're we're thrilled to
08:30have you in this role and everything
08:33Kevin said is true and more.
08:35So I'm going to take about 3 minutes
08:39and and just talk for a second or two
08:42about alignment between the healthcare
08:46system and the School of Medicine.
08:49I think it's fair to say that it
08:52with most of the history of the of.
08:55The healthcare system or what was
08:57originally the hospital, Yale,
08:59New Haven Hospital and the School
09:02of Medicine that the two didn't
09:05always work so well together.
09:07There has never been a joint strategic
09:10plan and I think for years and years
09:14you could accuse the School of Medicine
09:17of not being very helpful in terms of
09:20getting patients seen in the hospital,
09:22the faculty when I was a.
09:25Medical student and then a resident.
09:28Even the clinical faculty thought that
09:32the taking care of patients was a very,
09:34very, very parttime job.
09:37And at the same time,
09:38I think that the hospital didn't
09:41really recognize how important
09:43it was to be associated with a
09:46worldclass School of Medicine.
09:48All of that has changed now, I will say.
09:52In fairness,
09:53it changed in the Cancer Center in
09:57Smilo over the course of the past
09:59decade and long before I came here
10:02as a result of efforts that Tom
10:05Lynch and colleagues had made and
10:08then Laurie and Charlie had made.
10:11The two were, that is,
10:13the Cancer Center and Smilo
10:15were much more closely aligned.
10:18But what has changed on a system wide level?
10:22Is that Nancy Brown,
10:23the Dean of the School of Medicine,
10:26and Chris O'Connor,
10:27the CEO of the healthcare system,
10:29have really come together and
10:31decided that if we're going to
10:34be a great healthcare system that
10:36we have to be totally aligned.
10:39And there have been a series of meetings
10:43over the course of the last year,
10:45Lots and lots of discussions,
10:48a number of retreats.
10:50And it all just keeps becoming
10:53more and more real.
10:55And I think that what you will
10:57continue to see over the next year
10:59or two is greater and greater
11:01alignment between the two,
11:03both in terms of finances and
11:06in terms of strategy.
11:08And if we're going to be a
11:11great healthcare system,
11:12we really have to do this totally
11:15handinhand now, I'm pleased to say.
11:18That whenever Lori and I are in
11:20these meetings and retreats,
11:22everyone is always pointing to
11:24the Cancer Center is the
11:26example of how to do it.
11:28Now whether or not we really are
11:30the very best, I don't know.
11:33But we're happy to take credit for being
11:35far along this path and you can be sure
11:38that a lot of the work that's going
11:41to be done over the course of the next.
11:44Next couple of years will be piloted
11:47first in the Cancer Center and then
11:50will slowly trickle out to the rest
11:54of the the the two institutions.
11:56So you'll hear more and more about this.
11:59I'm going to say one other thing which
12:01is you may some of you may have also
12:03heard a term called funds flow and this
12:06manages to get some people very anxious.
12:09It doesn't make me terribly anxious.
12:12And it simply refers to a somewhat
12:16different financial relationship in
12:18the way that physicians and maybe
12:22ultimately other providers are funded
12:25by the healthcare system and and funds
12:28are transferred to to Yale Medicine.
12:31And for most of you,
12:33for virtually all of you,
12:35this should be something that
12:36just doesn't really affect you.
12:38It does affect it.
12:40It does affect the chairs to some
12:44degree because the whole all the
12:48decisions around hiring and productivity
12:51are going to be affected by this.
12:54But I don't think in the Cancer Center
12:56it's going to make a big difference.
12:58And if anything,
12:59I think it's just going to push us
13:01all to do our job a little bit better.
13:03So I'm happy to answer questions
13:05from people one-on-one.
13:06You know,
13:07anytime in the future you can call me,
13:09you can e-mail me, you can text me,
13:10you can do anything you want.
13:12But I wouldn't get remotely bent
13:15out of shape about this and I think
13:18I would just consider it part of
13:20the great alignment.
13:21And so that's really all I had.
13:24Laurie.
13:24I don't know if you want to
13:26make any additional comments.
13:28I was just trying to do this very briefly.
13:30No, I think it's great.
13:31You said everything that I think is
13:33important to be said at this point.
13:34I think that the only thing I add is
13:37that we will engage folks who are
13:41out there in the world of the Cancer
13:44Center and Smilo, this will be.
13:46A team sport like no other team sport.
13:50And so you know, we may not have
13:53the game plan completely mapped out,
13:56but I think we have a very strong strategy
14:00and vision for what that needs to look like.
14:02There are a lot of things that we are already
14:04beginning to execute on and I think that.
14:07We will learn as we go.
14:09We don't want to necessarily be
14:10completely prescribed because we
14:12believe that engagement is going
14:14to help drive a lot of what that
14:16ultimate road map looks like.
14:18And you know I think it's wonderful that
14:22cancer is being given the opportunity to
14:25to sort of get this out of the gate early.
14:30There are other service lines that will be.
14:33Right behind us that are high priority.
14:35So you know we want to make sure that
14:39we're thoughtful on how we do this so
14:41that you know it can help the rest
14:43of the the system in the school as well.
14:46So it's very exciting
14:49and you know we look
14:50forward to engaging everybody
14:52in this work. You
14:54all may or may not know this,
14:55but cancer is actually one of the top.
15:006 priorities of the university at
15:03large from a research perspective,
15:05I mean, the the university is
15:07obviously supportive of clinical care.
15:10But in in in the research world,
15:15cancer was not originally in the top five.
15:19They dealt with that not by removing one
15:21of the others that were in the top five,
15:23but by making it the top six. So.
15:26So we're there front and center.
15:29All right, Kevin,
15:30we'll turn it over to you and Kim,
15:37you're on mute.
15:40I think we may have asked
15:41go medical home next.
15:44We do great. I can share slides. Scott,
15:52as you're pulling it up, this is,
15:55you know basically an update from
15:58Michelle and her great team and
16:00all the work that's been done and.
16:02The two pilot sites,
16:03you know their frontline staff,
16:05their clinicians really has
16:08supported this work and so we
16:10wanted to thank all of you for that.
16:12The ASCO Patient Center in cancer care
16:15is a future kind of quality initiative.
16:19So kind of the next generation of of
16:22Kobe and Yale was one of 12 centers
16:26that really reached out to ASKO and
16:29worked on developing this pilot in 2021.
16:31And in doing so,
16:33we selected two clinic sites,
16:36so Smile of Guilford as well as the
16:38Smile of Breast Center and really
16:41got this PC-4 or medical home up
16:44and running at those two sites.
16:45And we were thrilled to see that
16:48we have those two sites accredited
16:50early this spring.
16:52And so really the next phase is to identify,
16:56you know,
16:56what we've learned from this
16:58program and make it better.
16:59And then over time,
17:00I'll roll it out across the enterprise,
17:02move
17:02on to the next slide.
17:06So why did Yale, sorry, and that's okay.
17:11So why did Yale participate
17:12in this in this pilot,
17:13it really allowed us to have a voice early
17:16during the development of this program.
17:18It allows us to demonstrate
17:20successful review of practices,
17:22making sure that we have high quality
17:24of cancer care delivery across the
17:26continuum and it really confirms value
17:28not only to patients but also to payers.
17:30The idea of this medical home is that
17:33unlike what's going on right now with
17:36value paste kind of payments where
17:38there's lots of different models
17:40more than say 30 or 40 nationally,
17:42the idea is that if we adopted this,
17:44there'd be.
17:44Kind of alignment across payment models.
17:47And so this is really a pilot
17:49to move that vision forward.
17:51And the goal over time is to replace
17:54the quote be which is relatively narrow.
17:57As Ken mentioned that it's mostly
17:59focused on outpatient administration
18:00of cancer therapeutics,
18:01whereas this program as you'll see
18:04in the coming slides really covers
18:06the entire cancer care delivery of
18:09of our therapeutics and management.
18:12Go to the next slide.
18:14So the purpose of this program
18:16really was to improve access to care,
18:18increase care coordination and enhance
18:21quality with attention at rising
18:23cost and and increasing efficiencies.
18:29The goals of the pilots that we had
18:31at our two sites and and really at
18:33the 12 sites across the country or
18:3512 systems was really to develop
18:37quality standards that build on
18:39prior works of a College of care
18:41model among other pavement models.
18:43And to really provide this framework
18:46so that we could identify key kind
18:49of quality measures and use those
18:52for future both quality improvements
18:54but also payment models.
18:56And Michelle's going to really focus
18:58on the seven kind of pillars of this
19:01program and the challenges and successes
19:03that we had at these two sites.
19:06Thanks, Scott. So as we look at
19:09what were the standards that we
19:12needed to implement with our teams,
19:15there were 7 standards in the
19:18ASCO Medical Home, what we,
19:20as we looked at how we were going
19:22to implement this across our sites.
19:26We decided to only do six of the
19:30standards and leave the chemotherapy,
19:32the Kobe standard,
19:34separate for this implementation.
19:36We really felt for two reasons
19:38that it was a lot for the team
19:40to take on and we were able to
19:42kind of stagger the certification
19:44because we were in that pilot of 1
19:47of 12 that we were still given the
19:50opportunity to keep this separate so.
19:53As we did that,
19:54it gave us a little bit of time to be
19:57able to kind of phase in some of the
19:59other standards with the pilot groups.
20:02So I'm going to in the next slide
20:04really go into what each of these
20:07standards are and kind of what we
20:10needed to do for each of those.
20:12So what we had to do and you'll
20:15see in in subsequent slides some
20:18snapshots of a little bit of our data,
20:20the first standard was around
20:22patient engagement.
20:23And so really this centered on how
20:25do we get information out to you know
20:28what is a medical home in our welcome
20:32packages to patients on our websites,
20:34any discussions that we're having.
20:37So really so patients understood.
20:40That we were,
20:41we were establishing a quality
20:43framework and also coordinated care.
20:45And within that we had to really
20:48look at also financial counseling,
20:51which was actually a bit of a
20:53challenge for us as far as all the
20:55requirements that Asko wanted us to
20:58meet in that that we did proactive
21:00financial counseling for patients.
21:02And so this was something that we
21:05worked really closely with the.
21:07Young New Haven patient financial
21:10counseling departments on how we could,
21:13how do we do things proactive and and
21:15we've got more work to do on this,
21:17but we really kind of identified some
21:20things that were really helpful for us,
21:22the access to care.
21:24So this is where we looked at patient
21:27tracking across the continuum from Ed visits,
21:31hospital admissions, readmissions.
21:33Also symptom triage and how patients
21:37accessed when they have issues,
21:39how do they access their care providers,
21:43Canceled appointments,
21:44missed appointments?
21:44Do we have processes for that evidence
21:47based care And this really was something
21:50that we really already had in place
21:53looking at our treatment pathways.
21:55All of our clinical research,
21:58this one I would say out
21:59of all the pilot sites,
22:01we were probably one of the
22:03leaders in this standard and and
22:05everything that we already had
22:07in place and actually many of the
22:09pilot groups kind of came to us to
22:12understand what we were doing.
22:13The team based care really it's
22:16talking about where are we at at
22:19the hub being the medical home,
22:20how do our teams work together,
22:22what is the communication look like,
22:24the medical oncology is directing that care,
22:27looking at all of our supportive services
22:29and and how do patients access that And
22:33then looking again at HealthEquity and
22:35are we looking at this is where we really.
22:39Came together with our colleagues
22:41at the Cancer Center of different
22:43HealthEquity projects that were that we
22:46are collaborating on quality improvement.
22:48So any of our quality improvement
22:50work that we're currently doing our
22:53performance improvement project,
22:54our plan through SMILO.
22:56And our patient experience survey
22:58and and one of the pieces of the
23:02patient experience survey was can we
23:04start providing A physician dashboard
23:08for their results.
23:10And so that was something that we
23:12implemented during this pilot and
23:15palliative care and end of life.
23:17So really looking at advanced care
23:20planning and patients goals at the
23:22end of life and developing clear
23:24processes for that.
23:28So as I get into the really kind of nuts and
23:31bolts of implementation and how we did that,
23:34I'd be remiss if I didn't mention
23:38really our key team that put countless
23:41hours as you're going to see.
23:43And in another slide Vicki Taiwo,
23:47Donna lapo Kara.
23:49Carol Esquivel and Chloe Shavlin really
23:53was the core team that did all the
23:57education and training and communication
24:00throughout this with our two pilot sites.
24:02Originally we had him,
24:04we were ambitious and we thought we would
24:07be able to implement the this program
24:10with all of our ambulatory settings.
24:12And really when we looked at that,
24:15it, it didn't make sense.
24:16We needed to pare it down.
24:18There was a lot of changes
24:20not only from a workflow,
24:21from a technology,
24:24just how we communicate differently,
24:27how we collect data.
24:28And so it made more sense to just pick
24:32two sites and as as Scott mentioned,
24:35that was our Guilford care
24:37center and our breast.
24:39Center and York Street and I
24:42really think that has allowed us
24:44to really look at how we can do
24:48this and expand this across our
24:52enterprise and by looking at our,
24:54you know,
24:55best practices and lessons learned.
24:59And so this is just kind of a snapshot
25:03what we went live as of January 30th with
25:07our of this year with our two pilot sites.
25:10So only five months in, you know this
25:13is just kind of giving you a sense of.
25:16Why It made sense for us to do 2 pilot sites
25:19then try to do this across the enterprise.
25:22There were countless hours of of
25:24meetings with our two teams of
25:27making sure that our nursing staff,
25:29our administrative staff,
25:30our physicians knew what we were doing,
25:33how we were doing it, training,
25:35rounding, making sure that you know,
25:38we were at the sites,
25:40not just doing this virtual and
25:43then really look.
25:44Looking at our infrastructure
25:46from a reporting and epic making
25:49sure we were testing and during
25:52this implementation and so all of
25:55this really was very important And
25:58during this we developed office,
26:00we had office hours, so our team.
26:03Every other week on a Wednesday or Thursday,
26:06we're there for 30 minutes.
26:08So any of the two teams could call and say,
26:11you know,
26:12we're struggling with this standard or
26:13we were having some problems with our
26:16technology or this isn't working correctly.
26:18And Epic and we could really in
26:21real time address their concerns
26:23and we did tips and tricks.
26:25So we would send things out that
26:28would apply to the nursing team or
26:30to the physicians or the front desk.
26:33Things for them to remember when we
26:36were doing our social determinants
26:38of health screening,
26:39how the workflow with with passing
26:42out our iPads and that's how we
26:44were doing the screening.
26:46So there was a lot we tried to make
26:49sure we were communicating and we
26:52were available as people needed us.
26:55So just to give you a little sense,
26:57I we took two of our measures.
27:00Which was our SDOH screening
27:02and our symptom triage.
27:04And so you know we're continuing I
27:07think to make some great strides
27:10from remember these were the SDOH,
27:13we were not doing the screening by iPad.
27:16So we were kind of start,
27:17we had done a pilot in.
27:21In 2019, but then with COVID,
27:24we had stopped that.
27:25So this is currently where
27:27we are for compliance.
27:29You know,
27:30there's a lot that goes into
27:33the workflow for the SGOH.
27:36So I'm really happy to see where
27:38we are and where we'll continue
27:40to be and with our symptom triage.
27:42This was a different way for us to be
27:45not just documenting when a patient
27:48calls on the phone for a medical form.
27:52This was are we documenting if
27:55someone has a fever or any or
27:58nausea that those things rise to,
28:01those symptoms rise to the top
28:02of the list so that somebody's
28:04responding in a timely fashion.
28:08And so part of the team,
28:11Donna and Chloe really wanted to talk
28:13about how do we continue sustainability.
28:16So we're five months in,
28:17we've got the summer coming.
28:19You know how are we going to keep this going.
28:21So they developed a summer incentive
28:24program and these were three
28:27of the measures that we were,
28:29we were hoping to track and it really
28:33was there's a baseball theme in this
28:36and so messages are going out and.
28:38There'll be some celebrations and awards
28:41on the teams in achieving the goals.
28:43And so you can see for our SDOH,
28:46our, our goal is 75% compliance.
28:50Our stretch is 85 with our symptom
28:53triage with our RN's again 75 goal,
28:5885% for a stretch and with our
29:01physicians with our electronic
29:03goals of care documentation,
29:06we raised the bar with our
29:07physicians a little bit.
29:08But based on our baseline data,
29:10the goal was 85% with a stretch of 90.
29:14So we will be monitoring that
29:16over the next several weeks.
29:18It just started I believe
29:19on the week of the 19th.
29:22And so we'll be monitoring this
29:23over the next couple of months
29:25and hoping to gain some momentum
29:28to to reach our goals on that.
29:32I wanted to share a little bit of a
29:36a patient story because one of the as
29:40part of our social determinants of health,
29:44we used community health workers
29:47as far as the screening.
29:50And so currently over the last
29:52five months we have to date we
29:55have 106 referrals have been made
29:57to our community health workers.
29:58So this kind of just gives you a little bit.
30:00I'm going to read this of.
30:02What's happening in with our
30:04community health workers and these
30:06are this one resource that we
30:08have for both of our pilot sites.
30:10This is a health system resource,
30:13it is not a smile resource and
30:17we're hoping to show a case that
30:20this really is working and hope
30:22that we will get more resources.
30:24Our community health worker received
30:26a late afternoon phone call from
30:28one of our social workers who is
30:30looking for assistance for a patient
30:32whose Medicaid coverage labs.
30:34The patient was scheduled for
30:35surgery the next morning.
30:37The community health worker was able to
30:39contact Medicaid for expedited service.
30:42The situation was resolved by
30:43removing an estranged family member
30:45from the account and reviewing
30:47eligibility and the patient received
30:49approval and coverage and was in
30:51place in time for her surgery.
30:53So it's really,
30:54really kind of depicts how important that
30:58this patient might have missed their
31:01scheduled surgery if the social worker,
31:04if the community health worker
31:06had not intervened in in that.
31:11And I'm going to just kind of summarize
31:13a bit for the next steps and then see
31:16if Scott has anything he wants to add.
31:18So as we're looking at over
31:20the next you know few months,
31:22we're we're rolling out our
31:24summer program looking at the
31:26sustainability as I mentioned.
31:27So we'll be continuing to monitor that.
31:30We are developing a dashboard for all
31:33of our measures and so that will be
31:37able to easily access the data and
31:40for our teams to be able to access the
31:42different data for the medical home.
31:44And we're really going to be working
31:47with our senior leadership.
31:49Our team has been working with Scott
31:52and Kim Slusser on what that might
31:54look like as far as expansion across
31:57our enterprise and I really think.
32:00Lessons learned and the best
32:02practices that we will see from our
32:05two pilot sites will really help us
32:07make some really good decisions.
32:09I think two things that we know right
32:13away that as it makes sense in certain
32:16sites that have the community Health
32:18worker resource we will be looking
32:21at the SDOH roll out and working
32:24with our care coordinators on making
32:28post discharge phone calls as part.
32:30Of our patient tracking.
32:31So those are two things that
32:34were really underway right now.
32:36Scott,
32:36is there anything that you'd like to add?
32:40No,
32:40I think you did a great job.
32:43This is just one program,
32:45there's there's several others and we're
32:47really looking for alignment across
32:49the programs and certainly engage.
32:51Everyone in the clinic as we think about,
32:54you know, do we phase this out
32:57clinic by clinic or intervention,
32:58you know, by intervention.
32:59So that's more to come in
33:01the coming weeks to months.
33:04Thanks everybody for your time.
33:09Scott and Michelle, thank you very much.
33:12This is an exciting program.
33:14I applaud your efforts as well
33:17as all of your team members who.
33:21I know have put as you said countless
33:23hours into this and I I think these are
33:25this is kind of the hard work that does
33:28improve care across our organization.
33:31No, I I think one of the things
33:34that we are aiming for under
33:37Doctor Weiner's leadership is to
33:39provide not just good cancer care,
33:43but the very best cancer care
33:46and part of that is bringing.
33:50Expertise to our patients,
33:51not just in the ambulatory setting
33:54but in the inpatient setting as well.
33:57And in an effort to do that,
34:00we will be launching a medical oncology
34:03specialty consult service for our inpatients.
34:08Liz Persich, our
34:13NP12 firm CHIEF has had this headed
34:17this organizational effort up.
34:19With the assistance of Ann Chang
34:21and of course the participation
34:22of all of our faculty.
34:24And I think, Liz, you'll be
34:26giving us the the rundown.
34:29Take it away.
34:33Give me one moment. I'm just
34:34going to share my screen here.
34:35Thanks for your patience.
34:39Are right. So I know many of
34:41you have heard this before.
34:42I'm going to keep the overview a little
34:45higher level for the group today.
34:48Disease specific oncology consults
34:49something that we have been working on
34:52for the past several months and Chang,
34:54Harry Deshpande and I have been
34:56collaborating closely with faculty and
34:58stakeholders from throughout Smiloan
34:59Institution and we're really thrilled to
35:02present the work we've been doing today.
35:04So to cut to the chase,
35:06starting on July 5th, we'll be working as.
35:09Disease specific oncology consults
35:11at the York Street campus.
35:13So our consult service will be staffed
35:16by 4 separate disease specific
35:18attendings coming from breast,
35:19head and neck.
35:20Thoracic will be combined,
35:22Ji and sarcoma will be combined
35:23as well as Gu and Melanoma and
35:25weekend and holiday coverage will
35:27remain unchanged with the general
35:29consultative model as before.
35:31This has really been a vision
35:33for the Cancer Center.
35:34I know Eric Weiner has been really
35:37a wonderful sponsor along with Roy
35:39Herbst and others to make this work a
35:41reality and to bring the best possible
35:43care to our patients on the inpatient side.
35:45So the goals of this project have
35:47been to create a disease specific
35:49medical oncology consultation on
35:51the inpatient side to really improve
35:53the care quality and continuity
35:55for our patients who are admitted
35:57during a true time of crisis.
35:59And as well as to improve the faculty
36:01experience by allowing them to focus
36:03within their subspecialty practice both
36:05outpatient and on the inpatient side.
36:09So I'll be reviewing the
36:11guiding principles today,
36:12the current and future state of the
36:15inpatient consultative service and how that
36:17relates to the inpatient care on MP12,
36:19some operational details and education
36:21and then end with a moment of gratitude.
36:24So the guiding principles of this
36:25are really to improve the patient
36:27care and experience through Med
36:29on disease based consultation.
36:31So when our patients, our loved ones,
36:33when we ourselves are admitted
36:35we want to see our.
36:37Primary oncologists or somebody
36:38who works closely with them,
36:40we want to improve the faculty
36:41experience through focus,
36:42subspecialty inpatient practice.
36:44We have such a wonderful focus,
36:47subspecialty,
36:47focus docs here and as we know
36:50cancer care has just become so
36:52some specialized and specific.
36:53We want to allow them to practice
36:55within their area of expertise
36:57in the inpatient setting.
36:58Furthermore,
36:58we want to promote excellent education
37:00as well as mentorship for fellows,
37:02residents and students,
37:03whether they're interested
37:04in oncology or not.
37:05I think there's so much our
37:07specialists can teach and provide to
37:10not just patients but our learners.
37:12And throughout this process,
37:13we've really focused on engagement
37:15of stakeholders from throughout the
37:17Cancer Center, throughout our faculty,
37:19our APP's,
37:20our nurses and we've been moving forward
37:22with as much transparency as possible.
37:23There's a lot of details and.
37:26It's been a really a labor of love
37:28over the past several months.
37:30So as we began this work,
37:32what we wanted to do was speak to other
37:34cancer centers to learn about what went well,
37:36what what we could learn from and and
37:38what other institutions have been doing.
37:41We've interviewed more than 420,
37:43brother.
37:43Cancer centers throughout the country,
37:46I wish they were in person,
37:47they were virtual and we learned about
37:49what other groups do in the inpatient side.
37:52Most places do have general consults
37:54where medical oncologist will see a
37:56variety of of subspecialties throughout
37:58the hospital regardless of disease type.
38:01Some groups did disease based
38:03consultation but focused
38:04primarily on new patients only.
38:06Others directly consult to the
38:09outpatient oncologist without a
38:11designated inpatient consultant per se.
38:13And then in select institutions really
38:17were able to promote comprehensive
38:20disease specific both inpatient and
38:22consultative care primarily at disease
38:25specific centers such as Sloan.
38:27So what we took away from this was the
38:30we identified an opportunity for Yale
38:32to really differentiate ourselves with
38:34the disease specific consult service.
38:36The inpatient commitment for our faculty,
38:38for faculty in the inpatient consult
38:40setting is variable and largely
38:42dependent on hospitals engagement.
38:44And I think I can speak for our team in
38:46that this disease specific work would
38:49not be possible without the wonderful
38:51support of our SMILO hospitals.
38:53There are different support models
38:55for the inpatient consultative
38:57services using an APP.
38:58We're very fortunate to have a dedicated
39:01APP on our consult service fellows,
39:04consults and nurse coordinators
39:05and also hospital support.
39:08So I'm going to go
39:09into the current model and the future model.
39:11So currently we have three attending
39:13staffing are two teaching services
39:14which we call Blue and White.
39:16Those are the teaching services
39:18primarily focused on MP12.
39:20And then a third physician from our
39:22oncology faculty who is a who works on
39:25the consult service with our fellow APP.
39:27Starting on July 5th,
39:28we're going to have four separate disease
39:30specific attendings that will be only
39:32practicing within their area of expertise.
39:34Again breast, head and neck,
39:36thoracic GI and sarcoma and Geo Melanoma.
39:39Of those four,
39:40two will be dedicated to attending
39:42teaching rounds in the morning with our
39:44house staff and our hospitalists and our.
39:47Medical students that are rotating on
39:49the inpatient service and another of
39:51those four faculty will be focused on
39:53the consult service and attend consult
39:55checkin rounds and will be available
39:57to see undifferentiated patients.
40:00So patients with new malignancy
40:02without a you know biopsy etcetera.
40:04So this is all starting July 5th.
40:07In effect, what does this mean for you?
40:10So when you place the console,
40:11everything is going to look
40:12the same on your end.
40:13You do the consult order the usual way.
40:15You can reach out to the
40:17dynamic role with any questions.
40:19All the attendings will be
40:21listed under Q genda.
40:23As usual.
40:23So you won't see a difference in
40:25terms of when you place that order.
40:26The difference will be that your
40:29patients will be seeing a disease
40:32specific oncologist within 24
40:33hours of the consult order.
40:36So I think that will be a huge benefit to
40:39your patients and and we'll be tracking,
40:41I'll get into this on the research bit,
40:43but we'll be tracking outcomes and
40:45metrics based on these major shifts so.
40:49Another big change that we've made
40:51with this disease specific work is a
40:53change in the education on this service.
40:55So with one attending rather than two
40:57attending on the teaching service we wanted
41:00to expand the opportunities for teaching.
41:02We have two separate afternoon sessions
41:04available per week where our disease
41:07specific oncologists and others will
41:09rotate through to offer learning
41:11opportunities and case based lectures
41:13not just for our house staff on the
41:15blue and white teaching teams but
41:17also for the for the consult team.
41:19A PP fellow and students and
41:22residents that are rotating.
41:24So those will take place on
41:26Tuesday and Thursday afternoons.
41:27I have a few pictures here of some of
41:29our faculty who have been participating.
41:31We've had fellows,
41:32we've had physicians not just
41:35from medical oncology,
41:36but surgical oncology and interventional
41:39poem infectious disease and others.
41:42And it's just been a really fun and
41:44wonderful way to learn about the care of
41:46our patients from many different viewpoints.
41:49So I encourage anyone who's
41:51interested in education,
41:52please reach out to me.
41:53We'd be happy to host you.
41:55I want to thank those of you who
41:56are on today who who've been
41:58involved for your efforts as well.
42:02Finally, I'll review.
42:03I think I've reviewed a lot of this
42:05already with the educational piece,
42:07but one specific dissatisfier that we
42:09learned about through our innovation
42:10work was for fellows that are
42:12rotating on disease specific teams.
42:14The burden of talking to four different
42:16attendings at a given time was really
42:19a challenge and detrimental to
42:21education and sanity to be honest.
42:23So what we've done is the fellows will
42:25be rotating only with two faculty at
42:27a time and they'll switch mid month.
42:29And I really want to express
42:31gratitude for us.
42:31Milo APP who's been supportive of
42:35this organization and transition
42:36to maximize the educational
42:38opportunities for our fellows.
42:40So they'll be deep diving into two
42:42disease subspecialties for the first half
42:44of the month and then the compliment
42:46of the second-half of the month.
42:47They'll be involved in the firm
42:49education as well and we're hoping
42:50not just to promote education,
42:52but also mentorship and the sense
42:53of community among the consult
42:55team and the inpatient team.
42:59So my final slide, I wanted to
43:01express gratitude to everyone who's
43:03been with us along this journey.
43:05The emoji represents not
43:07just prayer and preach,
43:08but I it's a high five as well,
43:10which I wasn't aware of and I
43:12think we can all be grateful for
43:13all the hard work we've done.
43:15And we're looking for the
43:16launching on July 5th.
43:18So next steps July 5th is our launch.
43:20We'll be having weekly checkins for
43:22the first eight weeks with incoming
43:23and outgoing faculty, fellows,
43:25students, APP's and hospitalists.
43:28We anticipate this will be an iterative
43:30process that will be changes.
43:31We can always make things better.
43:33So that is part of our plan and they'll
43:35be research forthcoming we'll be looking at.
43:38Time to consult,
43:39length of stay, readmission,
43:40faculty volume and feedback
43:42comparing pre and post launch.
43:44So I think you know this is a really
43:47unique opportunity that we have to
43:49learn about how disease specific
43:51transitions can benefit our patients,
43:53our faculty and our trainees.
43:56And that's all I have.
43:57I know Harry Deshpande and Anne Chang
43:59who've collaborated and supported
44:01this project from the get go are also
44:03on to answer questions and I'm just
44:06grateful for everybody's support as
44:07we've built this over the last five months.
44:12Thanks. We'll add that Liz is a
44:15total Wiz with the schedule and
44:18the service guide which which is a
44:21reference for anybody who wants to look
44:24at you know really the detail around that.
44:27Kevin, do you want me to answer
44:29that question or you want us to?
44:31You know, I think why don't we go ahead
44:33and get to Eric and we can circle
44:36back to it in the Q&amp;A period.
44:37I want to make sure we cover
44:40the drugs shortages when we
44:41kick it over to you, Eric.
44:44Cabbie safe. Dr. Weiner.
44:48All right, give me a second here.
44:50Let me just share my screen.
44:56All right. Could you see my slide?
45:00Yes, great. Thank you,
45:03Doctor Billingsley and good evening to
45:06those who are attending this town hall.
45:08As Doctor Billingsley mentioned earlier,
45:11oncology drug charges have made national
45:15headlines as hospitals clinics.
45:18Private physicians offices are
45:21challenged with obtaining drugs such
45:24as cisplatin and carboplatin and
45:27these drug shortages are negatively
45:29affecting our care to our cancer
45:32patients specifically these these
45:35the most recent drugs drug shortages
45:38started in late December of 2022.
45:40This was due to a generic
45:44manufacturing plant.
45:46Located overseas that halted production
45:48of their drug line per the FDA due
45:52to quality and documentation issues.
45:55And as you can see on the right,
45:57this is a diagram I pulled from the FDA.
46:01Approximately 37% of drug shortages are
46:05due to quality and manufacturing issues.
46:08This specific plant produced up to 30
46:12to 40% of some of the oncology drugs
46:16listed below for the US market and
46:19unfortunately it's not expected to
46:22resume production until later this summer,
46:25early fall.
46:28So where do we stand today with drug
46:31shortages within this Myelo network?
46:33The American Society of Health
46:35System Pharmacists is HP.
46:37As currently 240 medications
46:40with disruptions and drug supply.
46:44Eighteen of these drugs are oncology
46:48related and eight are currently
46:51critical drug surges nationally and
46:54within the elder haven health system.
46:57Again here is the list of the current
47:01oncology drug shortages that we
47:03are challenged with and just kind
47:06of go over them very briefly.
47:08BCG vaccine has been on worldwide
47:11shortage for over 2 years and
47:14currently the one drug that we have
47:16instituted dose limitations with
47:18specific patients receiving 130 dose.
47:21But we've been successful in
47:23obtaining a supply,
47:25a healthy supply and I have
47:27become a referral site for BCG
47:29treatment within the region.
47:31As I mentioned earlier,
47:33CARBO and Cisplatin are probably the
47:36most critical shortages that we are
47:38dealing with at this time and spent
47:40a lot of our work with the FDA just
47:43recently approved the importation of
47:46a Apple tax brand which is from China.
47:50And we are building and continue to build
47:53supply of cisplatin as well as carboplatin.
47:56And we're hoping soon that the
47:59FDA will also approve some type
48:01of impartation with carboplatin.
48:05Luthera being as a drug that we
48:07are watching very, very closely.
48:09We are micromanaging our supply
48:12to meet our patient needs.
48:15And then methotrexate just
48:17jumping down challenge,
48:18you know we're challenged with obtaining
48:21preservative free formulations as we
48:24utilize them for our intra fecal dose,
48:26all the other medications.
48:29We are watching those very carefully
48:32but we are always challenged with
48:35trying to obtain specific bio
48:37sizes or specific concentrations
48:40but but in summary we are.
48:43We currently do have enough drug supply
48:45to meet our patients needs with no
48:48clinical restrictions at this time.
48:50We are constantly communicating
48:52with our distributors,
48:54our drug representatives and
48:56understand the outlook of these
48:58shortages and immediately taking
49:00advantage of any supply releases
49:02and allocations through the drug
49:05committee themselves or a distributor.
49:08We we don't have a crystal ball.
49:10And what new drug surges may
49:12appear or the challenges that
49:14may suddenly come in the future,
49:17but we have created an evolving
49:19process to help manage our shortages.
49:23This is a little bit of a busy slide,
49:25but if you look in the upper
49:27left hand corner,
49:28the first step of this process
49:31is identification of shortages.
49:32And that really starts with
49:34escalation from our frontline staff,
49:36our clinicians who.
49:38May have trouble ordering the
49:40medications or have heard of potential
49:42drug shortages through colleagues or
49:45listers across the country or that
49:47may be using different distributors.
49:50And I I just want to stress that you know,
49:52you know escalation is extremely important.
49:56You know this is is where it makes a
49:59difference where we could potentially
50:01be able to build an overstock of
50:03you know one to two months supply.
50:05Or you know,
50:06we are now facing a drug shortage that
50:09may occur within one to two weeks.
50:11Once we hear about the drug shortages,
50:14pharmacy will investigate,
50:16conduct and impact analysis,
50:19monitor the situation depending on the type,
50:22the cause or predicted duration
50:24of the shortage.
50:26We have weekly and sometimes
50:28daily meetings about shortages,
50:29depending on the drugs and
50:31severity of the shortages.
50:33We then will brainstorm,
50:35implement and mitigation strategies
50:37such as maximizing our allocations
50:40through our multiple locations,
50:43move to multi use of vials if appropriate,
50:46recommend drug alternatives,
50:48toast rounding and lastly
50:51clinical restrictions.
50:53Finally, there is work with procurement,
50:56storage and redistribution.
50:57We have made our Smilo Cancer Hospital
51:01pharmacy located on the 8th floor
51:04as an Overstock hub and through
51:07this hub we distribute medication
51:10throughout the Smilo network.
51:13We address any type of storage constraints,
51:17but we also have to be cost conscious too,
51:19especially in this challenging
51:22financial environment.
51:24So I hope was able to provide you a quick
51:26summary of our current drug shortages.
51:29Happy to entertain any questions,
51:32but before I do,
51:33I really want to thank the technicians,
51:36the pharmacists,
51:37the clinicians,
51:38our procurement team who are really,
51:39really involved to the daytoday
51:41management of these shortages.
51:42They have been truly amazing
51:44and building our current drug
51:46supply and assuring that we are
51:48able to provide these lifesaving
51:50drug treatments to our patients.
51:52Thank you everyone for your time.
52:00Roy, Roy, what am I saying,
52:02Kevin, if I can just add a word.
52:04Thank you, Eric.
52:06You know, around the country
52:07this has been a huge problem.
52:08In some places there are
52:11incredibly severe drug shortages.
52:13I congratulate our pharmacy here for
52:17not running into this same problem.
52:20It's really complicated.
52:21ESCO has been trying to
52:23play a major role in this.
52:26As Rick Pastor told us at at ESCO when
52:29he came to meet at the ESCO board.
52:32It's actually doesn't fall
52:33into the purview of the FDA,
52:36but there's their attempts to lobby
52:40Congress to try to have a larger
52:44storehouse for drugs like these.
52:46And as Eric said,
52:48much of this relates to problems
52:50in the manufacturing system
52:52in at at overseas sites.
52:55It's it's really challenging and I
52:58think what frustrates many of us so
53:01much is that it's also in many ways
53:03a symptom of the fact that the drug
53:05industry of course is fundamentally
53:09geared towards making drugs that.
53:12Turn a big profit and these drugs
53:14which are of course generic
53:16and do not result in a profit,
53:18just get ignored and we got to
53:19come up with some better way
53:21of dealing with this situation.
53:27So
53:29thank you. I think it,
53:30I I will say as a surgeon this is
53:34not a problem that is unique to the.
53:37The medical side,
53:38we're also experiencing supply
53:40chain disruption in operating room
53:43equipment and sterile supplies.
53:45So this is
53:48kind of spanning the the breadth
53:50of all of our healthcare operations
53:53and it is truly stretching us all.
53:56And I think unfortunately I have
53:58to agree with you doctor Weiner
54:02devices and products that
54:04are not lucrative tend to be.
54:07Supply chained in a precarious
54:09way and we were feeling this. Now
54:15let me just maybe ask the first question.
54:19I don't see other questions in
54:21the chat or the Q&amp;A right now
54:23unless I'm missing anything.
54:25Kim, are you seeing anything?
54:26No, I just, I didn't want to forget
54:29about the question that somebody put in
54:32for around the inpatient consulting.
54:35Maybe we could.
54:35I don't see that written right now.
54:37And do you remember what that is?
54:39Could you answer that we put off earlier?
54:42Sure, I I answered it,
54:45but then it goes to a different screen.
54:46So the question was will the new
54:49plan structure be able to move the
54:52goals of care conversations forward
54:53when appropriate when patients are
54:55admitted and at the end of life,
54:57how will the multidisciplinary team members
54:59be involved in this new structures?
55:02Structure in relationship to planning
55:03for the patient needs discharge barriers
55:06to care and this is a great question.
55:08It must be very informed because
55:10this is basically one of the
55:12exact reasons why we think this,
55:14we wanted to do this and why we
55:17think it's going to really help
55:18the patients is that if you have a
55:21lung cancer patient who's there.
55:24And and and the attending on service
55:27previously was a breast cancer patient,
55:30breast cancer doc.
55:33That breast cancer doc is really
55:35not going to feel as comfortable
55:37discussing the ins and out of what the,
55:39what the possible treatments are and
55:42what the prognosis is for this patient,
55:45for a new patient that breast cancer
55:47doc who's a fantastic breast cancer doc,
55:50but it's not going to feel as comfortable.
55:53Moving the the work up and and
55:55asking for the what what the the
55:58latest you know tumor profiling or
56:02or those types of details that would
56:05inform the patient's care.
56:07And so we think that that's going to
56:09really help the patient get a faster
56:11work up and a better work up and I
56:14think that our surgeons who have been
56:17doing this for a long time Kevin you see.
56:19GI patients and and you don't you're
56:22not seeing general surgery patients.
56:25So I think you guys are have expressed
56:27to us on on different calls that
56:29you're really excited about this plan
56:32and and I think overall it's going
56:34to be real satisfier for patients
56:36and and for docs and staff,
56:38I don't Liz or Harry if you want to add.
56:42I was going to add,
56:43I think you know we're we're kind
56:45of effectively taking out the
56:46middleman or removing one line of
56:47this telephone game that we have.
56:49You know let me talk to this doc
56:50and we talk to that doc.
56:51We're a little bit closer to the
56:53patient's primary if not actually
56:54the patient's primary at the bedside.
56:56And I think we can have these assumptions
56:58and hopes that this will be how it will work.
57:00But we're also going to
57:01be looking at the data.
57:02So we're going to look at length this day,
57:04we're going to look at their readmissions,
57:05we're going to look at their.
57:07Mortality in their Hospice
57:08utilization and see if you know
57:10talking to their primary earlier
57:11is making a concrete difference.
57:13I know from a patient and caregiver
57:15perspective that that would make
57:17a big difference for me,
57:18but what is the data show us and
57:20we'll be looking at that certainly.
57:21So anonymous attendee,
57:22thanks for you for your question.
57:24Yeah. And Liz, I just want to point out
57:26that both with this initiative and the
57:29ASKO Medical Home that both of the teams
57:32working on this engaged our patient
57:34and family Advisory Council and their
57:36feedback informed some of this work.
57:39And I just really think that's
57:40important as we continue to move
57:42forward with our initiatives that
57:43we're engaging our patients and the
57:45voice of our patients in that work.
57:47And so I I think we honored what
57:50the feedback that we got from them
57:52and both of these projects and.
57:54Looking forward to seeing the
57:55results of the of the service and
57:57same with from the nurses,
57:59I think we the the inpatient nurses
58:01here all the time from patients
58:03that they want to either see their
58:05oncologist or see somebody who
58:08understands you know their cancer.
58:10So I I'm real excited
58:12about seeing the outcomes.
58:19Well, on that note,
58:20I think I'm going to thank all of
58:23our panelists and and participants
58:25for being here this evening.
58:27A lot of exciting things happen
58:30happening and more than anything,
58:33I know Kim and I want to express our
58:35gratitude to our teams that are working
58:37hard to care for patients and families
58:40to cross the organization every day,
58:42keep up the good work and also
58:44make some time to enjoy the summer
58:47with yourselves and your families.
58:49Have a great evening.