Oncology hospital in the home
What changed?
- During the COVID-19 pandemic there has been rapid uptake of in-home care, including home-based intravenous (IV) chemotherapy administration. Australian private health funds reported a 50-80% increase in patients seeking chemotherapy at home during the pandemic.
- In-home oncological care was facilitated by initiatives such as nurse-led telehealth models1 and the Australian Government’s COVID-19 National Health Plan, which provided interim arrangements for prescriptions, such as home delivery of medications.2
Impact of change
- In-home oncology models may help to effectively utilise healthcare resources and to reduce the risk of acute care facilities being overwhelmed during the pandemic.1
- In-home oncological care can reduce hospital-related complications, minimise the risk of community transmission of infectious diseases such as COVID-19, protect the wellbeing of immunocompromised patients,3,4 and improve patient-centred care.5
- At the same time, in-home care has inherent risks.6
- There are concerns around the safety of home infusions of chemotherapy drugs; routine use could potentially fail to provide the safeguards to both patients and health care providers, thereby exposing both to unnecessary risk,6 and potential medicolegal risk in staff working outside the clinical setting to provide treatment. There are also fewer opportunities for review by other team members, for example a breast care nurse, and fewer opportunities for treatment adjustment, such as dose reduction or blood transfusion on the same day as treatment.1
- In-home oncology models for chemotherapy also potentially heighten inequities in access for rural and remote populations, for example, due to challenges in safely and efficiently delivering drugs requiring cold chain transport over greater distances and diverting resources from providing better access in regional areas.1
How can high-value changes be embedded or enhanced?
The following strategies were identified in Australian and international literature and by leading Australian cancer experts and consumers. This list is provided to prompt considerations and future strategies to support high-value cancer care in the Recovery phases of the COVID-19 pandemic.
These strategies are listed at the system-, service-, practitioner-, and patient-levels and are intended to be used by a range of cancer control stakeholders across Australia to support high-value cancer care and improve outcomes for people with cancer.
System-level strategies
- Developing and implementing policy and guidance for safe and efficient administration of IV chemotherapy in the home to ensure minimum standards for facilities to deliver chemotherapy are maintained.7
- Developing policy and regulatory-level guidance to enable high quality and sustainable provision of home delivery of medications, including oral anticancer therapies, via community pharmacies.8,9
- Undertaking cost-effectiveness evaluations of chemotherapy delivery in the home for the health system.
- Implementing electronic prescribing to improve medication safety and efficiency in the medication management process, by reducing medication errors, through improved prescription legibility, dose calculation and clinical decision support; reducing administrative workloads and improving linkages between clinical information systems.1,7,9
Service-level strategies
- Developing standardised triage protocols informed by patient-reported outcomes,1 to assess patient preference and eligibility for home-based care.10 Whilst this has the potential to reduce clinic visits, assessment of the impact on patient outcomes needs to be undertaken.1
- Investing in medical and human resources to enable safe, quality and efficient in-home care for people with cancer.1
- Detailed escalation plans in place for managing treatment complications, in order to ensure delivery of safe and quality care.7
Practitioner-level strategies
- Training for health professionals, including cancer nurses, physicians and pharmacists, to meet standards for adopting in-home oncology models for the provision of delivery, or provision of virtual support in the delivery, of anticancer therapies in patients’ homes.1,8,10,11
Patient-level strategies
- Empowering patients and their families to safely self-administer treatments (via oral or subcutaneous routes), with virtual support from healthcare professionals.1
- Increasing awareness through patient education of the benefits but also potential risks of home-based oncological care.
- Facilitate remote access to psychosocial support services for patients and their carers.
- Assessing patient acceptability of home-based oncological care and potential barriers to the delivery of optimal cancer care in the home.
References
[1] National cancer expert or consumer participant. Cancer Australia COVID-19 Recovery and cancer roundtable. Meeting minutes unpublished. 30 July 2020.
[2] Australian Government Department of Health. Coronavirus (COVID-19): National Health Plan resources. 2020 [cited 2020 September]. Available from: https://www.health.gov.au/resources/collections/coronavirus-covid-19-national-health-plan-resources.
[3] Asgari P, Jackson A, Bahramnezhad F. Resilient care of the patient with COVID-19 in Iran: a phenomenological study. 2020. doi: 10.21203/rs.3.rs-24733/v1
[4] Weinkove R, McQuilten ZK, Adler J, et al. Managing haematology and oncology patients during the COVID-19 pandemic: interim consensus guidance. Med J Aust. 2020;212(10):481-9.
[5] Nelson R. 'Hospital at Home' cuts ED visits and costs for cancer patients. Medscape; 2020 [cited 2020 Jun]. Available from: https://www.medscape.com/viewarticle/932135.
[6] American Society of Clinical Oncology (ASCO). American Society of Clinical Oncology position statement home infusion of anticancer therapy. Virginia, United States: ASCO; 2020.
[7] Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards user guide for medication management in cancer care. Sydney, NSW: Australian Commission on Safety and Quality in Health Care; 2020.
[8] Koczwara B. Cancer survivorship care at the time of the COVID-19 pandemic. Med J Aust. 2020;213(3):107-8.e1.
[9] Australian Commission on Safety and Quality in Health Care. Electronic medication management systems - a guide to safe implementation (third edition). Sydney, NSW: Australian Commission on Safety and Quality in Health Care; 2019.
[10] Chan A, Ashbury F, Fitch MI, et al. Cancer survivorship care during COVID-19-perspectives and recommendations from the MASCC survivorship study group. Support Care Cancer. 2020;28(8):3485-8.
[11] Dickson HG. Hospital in the home: needed now more than ever. Med J Aust. 2020;213(1):14-5.
