Atrium Health: Pioneering Outpatient Transplant Models Driven by Pharmacist-Led Care

In an interview with Pharmacy Times, LeAnne Kennedy, PharmD, BCOP, CPP, FHOPA, oncology clinical manager at Atrium Health Wake Forest Baptist in Winston-Salem, North Carolina, shares insights about the facility’s Wake Outpatient Transplant Program and highlights its positive impact on patient care outcomes.

Pharmacy Times: What was the initial motivation behind launching the Wake Outpatient Transplant Program?

LeAnne Kennedy, PharmD, BCOP, CPP, FHOPA: So the initial kind of motivation was twofold. There's financial motivation for the institution. With reimbursement, with transplant, it really was going down. When I started transplanting 30 years ago, we were getting like $150,000 reimbursement for an autologous stem cell transplant, and then it slowly eroded away, and now it's like only $30,000 for reimbursement.

So how do you do that in a cost-effective way to be able to keep the doors open and everything like that? One part of it was financial. And we actually found that if you can give medications and you can get the stem cells in an outpatient setting, you can do it cheaper. You can use 340B drugs. And so it really does help.

So there's that. But then it's like, for our patients, at first they were very anxious, and they're like, “What do you mean I'm going to do this outpatient?” I'm like, “But you get to sleep in your own bed.” So then it was really working on the patient and their quality of life and being able to prevent infections and really allowing them to sleep and rest and be at home.

Ultimately, it probably started off as financial and then really tried to look at it from the patient’s perspective.

Pharmacy Times: What patient needs or institutional gaps did the program aim to address at the outset?

Kennedy: I think we had to kind of sell patients on it. As I said, if you read anywhere—especially, we've been doing this for 10 years now—it’s hard to believe there weren’t a lot of institutions doing outpatient transplants.

So if patients are doing research about transplants, what they read and hear on the internet is that it’s all inpatient. And so they're like, “What do you mean?” So we had to help them overcome that anxiety about it and help them see what it was and how that can be beneficial. There was some of that kind of selling them on the idea.

Then we also had to make sure that every patient had a caregiver that was there with them 24/7. And that's a challenge, because in some ways, when they come in the hospital—don’t quote me on this—but they kind of can get dropped off and let the nurses and the team take care of them, and then pick them up when they're done.

So this is really an investment on the caregiver—to have to give time and everything, either getting them to and from, being there with them, but then also being there at night and at home with them.

Pharmacy Times: What were some of the biggest clinical or logistical challenges you faced when starting the program?

Kennedy: Some of it is trying to find the space for it and trying to figure out who the right people were. I was talking to a new transplant pharmacist, kind of helping them to see where we started. When we started, we had probably 100 people who met every week to try and figure out how we were going to do this.

There were physicians, there were nurses, there were pharmacists, and there were IT people. There were housekeeping, dietary, respiratory therapy—I mean, all of these people—and we had to go, “Okay, this takes a village to make this happen.” So really, that logistical part of how do we do that?

We would break up into work groups and go, “Okay, for pharmacy, how are you going to make sure that they have the right meds? How are you going to make sure that we can get the meds to the patients at the right time? What pharmacy is going to do it? Is it the inpatient pharmacy? Is it the outpatient pharmacy?”

And then also just trying to find space. There are outpatient transplant programs that do it in their clinic, and their clinic is open from seven in the morning to seven at night. We do it in our inpatient unit, and that allows those same nurses that take care of transplant patients every other day to take care of them in the outpatient setting.

So it was really trying to decide what’s the best thing for our institution. Clinically, it was training and coming up with things without having a lot of other people’s experiences. It was kind of like, “I don’t know how to do this, but we’re going to try it this way and see how it goes.”

We started small. We started in one disease state. We did it partly outpatient, and then we moved inpatient, and then we eventually took that all the way outpatient. Then we went to another disease state, and then we went to CAR T. So it is growing, and now we're looking at how we can do this for allogeneic transplants.

Pharmacy Times: What metrics are currently being tracked to evaluate the success of the program (eg, hospital readmissions, medication adherence, graft survival)?

Kennedy: We are writing through our notes and things like that, and through data collection, we're looking to see how many of our patients can stay outpatient the whole time. How many of them have to get readmitted? Are they readmitted for nausea or vomiting? Are they admitted for febrile neutropenia? Can they go back outpatient?

We’re looking at the cost savings with that. We're tracking pharmacist interventions to see what all the pharmacist is doing with each patient and looking at cost savings that go along with that. Medication adherence is hard, so we haven't tracked medication adherence, but it is definitely something that for every patient we are looking at, we are trying to help them with.

We have a medication calendar that we give to each patient, and anytime we make a change, that calendar gets updated, and we highlight the things that we're changing with that—making sure that their family members that come along with them have that as well. So they have a notebook, and we really go through that every day.