Reinventing Transplant Care: From Inpatient Tradition to Outpatient Innovation

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, highlights the extensive role of pharmacists in the Wake Outpatient Transplant program.

Pharmacy Times: How are pharmacists integrated into the outpatient transplant care team, and what roles do they play in patient management?

LeAnne Kennedy, PharmD, BCOP, CPP, FHOPA: I think this is one of the exciting things. Our pharmacists are there from the very beginning, prior to them ever being a patient or ever coming to transplant. We have an education session, and even before that education session, we're reviewing the plan to make sure that it's correct.

And then we in North Carolina have the ability to prescribe medications through the CPP—the clinical pharmacist practitioner. So we are licensed by the medical board and also by the board of pharmacy. Not everybody, but transplant was kind of the first one in oncology.

So we'll send the prescriptions that they need to our specialty pharmacy and then get those meds and bring them to the patient prior to them ever coming to transplant and go, “Okay, these are the meds you're going to take. Let's go over what you're taking at home. Now let's talk about what we need to take. Are there crossovers? Do we need to hold some things? Do we need to start some things? Do we need to talk about what they're doing?” That gives us a bond with our patients.

So we're there, and then we see the patient every day. We see them to make sure they're taking their medicines. We make sure that if they're having nausea or vomiting, we're adjusting their medications or their anti-nausea medicines. If they're having diarrhea or constipation, we're the ones really helping with that.

Then as they are getting closer to going home, we're setting them up for what meds they need to go home with and then counseling them about that so they have success when they go home.

Pharmacy Times: Have you observed any improvements in patient outcomes or satisfaction since the launch of the outpatient model?

Kennedy: One of the things was going from a hybrid model—where we started outpatient and then, like on day plus one, we admitted them—to being able to say, “Okay, now we can do it all outpatient until they have febrile neutropenia or nausea, vomiting, or something that requires them to come in.” Looking at that is a way of tracking the success of that.

So we can say, “How many days saved for length of stay have we been able to achieve?” I think that is something. I think it would be a really great thing to track patient satisfaction—patient-reported outcomes. What do they think about this? They tell us that they like it and they appreciate it, but do we have hard numbers for that? Unfortunately, we don’t. But that sounds like a great research project for next year.

Pharmacy Times: How does the team ensure smooth transitions from inpatient to outpatient transplant care, particularly regarding medication management?

Kennedy: So I think making sure that we have the right medications in the right place, making sure there's communication with the dispensing pharmacy—whether that’s the outpatient pharmacy or, because our patients are in the inpatient tower, the inpatient or acute care pharmacy dispensing those—then we have to make sure it's reimbursed correctly.

So there were a lot of things. It's not just about, “Oh, let’s give them their nausea medicine,” but let’s make sure we get it to them correctly and in a timely fashion. So making sure the right medicines are coming from where they need to be and that it’s not hard for the nurse to get them. Those are really some things we had to make sure were correct: the information and then delivery to our patients.

In most hospitals, you have what's called “meds to beds,” where the outpatient pharmacy will fill the discharge prescriptions and bring them to the floor. Well, this is an outpatient unit. And so they’re like, “This doesn’t apply to us,” and I’m like, “But it does.”

So we really had to work on changing perceptions, even within the Department of Pharmacy, to say this is still the same kind of thing. It just sounds like it’s outpatient. I mean, it is outpatient in semantics—or it truly is outpatient—but we’re just trying to meet the needs of the patient. So we've worked together to try and find the right way to take care of those patients.

Pharmacy Times: What elements of the program are still evolving or being piloted, and what’s next for the outpatient transplant initiative?

Kennedy: Really, the part that's kind of evolving now is our CAR T patients—those going through cellular therapy—and trying to make sure we can keep them outpatient as long as possible. These are even more expensive therapies, and so if we can do this outpatient, that is really the best thing for the institution, but also for the patient.

We actually had the patients, when they were doing this, come in twice a day—so they'd be here in the morning, they'd go home, and then they'd have to come back in the afternoon for an afternoon visit, and then do a video visit at night. Now they just come in once a day and do two video visits.

So it's a way to really minimize them having to come back and forth.

Our next thing that we're looking at is how do we do allogeneic stem cell transplants in the outpatient setting? Again, I think that'll be a hybrid. I think it’ll be chemotherapy—maybe their cells being given outpatient—and then, as we hit their hardest time or their highest risk for either febrile neutropenia or mucositis or even some of the toxicities from the chemotherapy, we have them inpatient until we feel comfortable, and then transition it so that it could be all outpatient.

Pharmacy Times: Do you envision expanding pharmacist involvement in other areas of transplant care or across other specialties using lessons learned from this program?

Kennedy: With bispecifics being such a key and evolving area, I think this is something where we've taken what we’ve learned through our CAR T outpatient process and applied that to our bispecifics. That is something we have definitely taken from transplant and shared with our other bispecific programs—especially now that we do bispecifics in solid tumors.

Now, because Atrium Health is not just Wake Forest but also includes Atrium in Charlotte with their transplant program, we've been able to share what we do outpatient, and now they've started their outpatient transplant program down in Charlotte.