Smilow Cancer Hospital Town Hall | January 24, 2024

January 25, 2024

Information

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

New Clinical Announcements

Kevin Billingsley, MD, MBA

Tracy Carafeno, MS, RN, CNML

Latest Advancements in Patient Care

RefleXion Radiotherapy: Exclusively in the Northeast at Smilow

Henry Park, MD, PhD

Critical Policy Changes

Genetic Testing Referrals & Ordering

Veda Giri, MD

Early Release of Medication Orders

Man Yee Merl, PharmD, BCOP

Patient and Family-Centered Care

Improving Patients’ Quality-of-Life through Supportive Care

Madelyn Kaehler

ID11215

To CiteDCA Citation Guide

00:00Welcome to this Milo
00:02Cancer Hospital Town Hall.
00:04We're very thankful and appreciative
00:06of everyone taking time to join
00:08us this evening and hopefully
00:09going to provide you with some
00:11really exciting news and updates
00:15just to go over the agenda quickly.
00:16Doctor Billingsley and myself will
00:19do some quick announcements and
00:21recognition and then we are going to
00:25hear from Doctor Henry Park regarding
00:28Reflexion radiotherapy exclusively
00:30in the Northeast at Smilo. Dr.
00:33Vita Guerra will talk about genetic testing,
00:35referrals and ordering.
00:36And then Mandy Merle is going to
00:38speak to us on early release of
00:41medication orders followed by Maddie
00:43Callahan who will be talking about
00:45improving patients quality of life
00:47through our excellent supportive
00:48care program that she's leading.
00:50And then we do have question and
00:53answer session that will be moderated.
00:55There's a chat that you can put and
00:58some were sent in ahead of time.
00:59So we'll be hopefully giving time
01:02for questions and responding to that
01:04chat throughout the presentation.
01:08I'm going to turn it over
01:09to Doctor Billingsley.
01:10Yeah, thank you, Tracy.
01:12And again, I also want to extend a
01:15note of welcome and gratitude for
01:17people taking the time to be here
01:19despite the winter dreary weather.
01:23We have lots of exciting development
01:26and growth and SMILO and the Yale
01:29Cancer Center and the cancer enterprise
01:32across the organization and it's just
01:35wonderful to bring these updates.
01:37I first wanted to take some time to
01:39talk about growth and development
01:41in the Center for Thoracic Cancers.
01:44As this community knows,
01:46this has been one of our true signature
01:50programs and has been a program which
01:53has not only provided outstanding
01:56clinical care across the organization,
01:58but has been an engine of clinical
02:02trials and research that have really
02:04delivered life changing therapy
02:06to lung cancer patients across
02:08the country and around the world.
02:10And like all great organizations there,
02:13we have been going through an exciting
02:16leadership change in development.
02:19And in recent years,
02:20this program has been under the really
02:23wonderful stewardship of Doctor
02:25Roy Herbst and Doctor Dan Boffa,
02:28medical oncology and surgical
02:31oncology leaders.
02:32And I would also be remiss if I did
02:35not mention the strong history of
02:37this program that developed under the
02:40leadership not only of Roy and Dan,
02:43but of Frank Detterbeck,
02:45Doctor Lynn Tenui and of course
02:48the incomparable Roy Decker.
02:50So just a moment to to reflect
02:53on their contributions and be
02:55grateful for them as well.
02:57But the exciting new chapter
03:00in thoracic oncology,
03:01we do have new leadership coming
03:03forward and doctor Sarah Goldberg,
03:06Medical Oncology Associate Professor
03:08has stepped forward and she will be Co
03:12leading with doctor Justin Blasberg,
03:14thoracic surgery,
03:15thoracic surgical oncologist,
03:18associate professor in the
03:19Department of Surgery.
03:20Both of these are remarkable clinicians,
03:23researchers and leaders in our
03:27organization and it's exciting to see
03:29them both step forward to take a more
03:32prominent role in this terrific program.
03:34So Sarah and Justin,
03:36welcome and thank you.
03:38We know the program's going to
03:41continue to thrive under your guidance.
03:44Next please.
03:47As a gastrointestinal surgical oncologist,
03:50I'm particularly excited to share
03:54this next piece of news and
03:56development is the audience knows
03:59the Center for Advanced Endoscopy
04:02has been for many years a pillar
04:06of our GI oncology program.
04:09The services that this group of
04:12gastroenterologists offer are truly
04:14remarkable ranging from endoscopy to
04:17ERCP to stent placement to endoscopic
04:20ultrasound to very complicated both
04:23therapeutic and palliative interventions
04:26for patients with GI cancer.
04:29It's a unique set of services really in
04:32the state and they offer some of the
04:35most innovative procedures in the Northeast.
04:38Doctor Jamadar has been really at the
04:41forefront of this for many years,
04:43has been a steward of the program
04:47and a trailblazer in this area.
04:49He will continue to see patients
04:52and be a very active clinician
04:55and advisor in the program,
04:57but the torch of leadership will
05:00be passing to Doctor Thiru Muniraj.
05:02Many of you know Thiru Thiru is an
05:06outstanding individual.
05:06He's a wonderful clinician.
05:08He's beloved by both his
05:10colleagues and his patients.
05:12And I think it's really well
05:15positioned to lead the center
05:17in the future months and years.
05:19So very excited to share this development.
05:22Next I'll kick it back to you, Tracy.
05:27Yeah, and we are also excited
05:30to announce that Angela Carrera
05:32will be joining us as the interim
05:34Manager for oncology social work
05:36across the Smilo enterprise.
05:38And Angela comes with a lot of
05:41knowledge and commitment to our
05:43patients over the last decade in SMILO,
05:45She has worked in the SMILO
05:48Survivorship Clinic,
05:49the Breast Center and the Psycho
05:51Oncology program and brings a lot
05:54of experience in leadership to work
05:56with our teams as we move and develop
05:58social work across the continuum.
06:00So we look forward to Angela coming
06:02on board and she will be coming
06:05to a town hall soon to share sort
06:07of her vision for social work
06:09in the next few months.
06:14We wanted to give
06:15you an update on you know sort of the
06:18hospital surge that's currently happening.
06:21I think most people are aware that we've
06:24been in a sort of a surge operations for
06:28the last several weeks and it it seems to
06:31progress each day to a worse situation.
06:33This is just an example from this morning
06:36of where we stood when we started the
06:39morning with our total census and you
06:41know capacity at both organizations.
06:43I think what we really want to highlight
06:46here is that there were 74 patients
06:48boarding in the Ed this morning.
06:51Those are patients waiting that are
06:53already have admission orders but no
06:55bed to be assigned and nineteen of
06:57them had been there over 24 hours.
06:59So as everyone understands,
07:01that's a really unsafe situation and
07:04we've had some serious safety events
07:06in the Ed due to overcrowding and if
07:09anyone's walked down there during this
07:11time it's it's it's like a war zone,
07:14it's very concerning.
07:15So several things are being put into
07:19place to try and alleviate some of
07:22the burden in the Ed As of today.
07:25Hallway beds have been used in the
07:28medicine service line for quite
07:31a while during these surges,
07:32but it has opened up and now
07:35will include three of our units,
07:38NP 1214 and 15 in Smilo.
07:40But it's also opening up to all,
07:42many of the other surgical units
07:45across all of the towers.
07:47They are seeing a significant number
07:49of surgery patients boarding in
07:51the Ed which is a new phenomenon.
07:53So these will be patient with,
07:55these will be our own patients and
07:58there are exclusion criteria as as far
08:01as who is appropriate to be in the
08:03in those hallway beds and each unit
08:05will have one designated hallway bed.
08:08They are encouraging.
08:09We are encouraging people to pursue
08:12outpatient evaluations for non urgent
08:14issues and there was discussion of
08:17sort of social media and campaigns
08:19again around using urgent care
08:21centers instead of the Ed.
08:23We also have the closer to home
08:26lounges that we can send patients
08:28to that are staffed with APCA.
08:31Those are patients who are ready to
08:33go home but you know don't have a
08:35ride and need to wait for a while.
08:37And then as a reminder,
08:39we also have the home hospital
08:41inpatients can get transferred to
08:43home hospital if they're not quite
08:45ready to go home alone and and sort
08:48of ready to launch from the hospital
08:50and there is a a whole team that works
08:53on facilitating that if we identify patients.
08:56So we're we're asking everyone to
08:58sort of get on board in this endeavor
09:00to try and really ensure that we can
09:03move patients through our system in
09:05order to get new patients is it's
09:07a it's a good thing that we have
09:09volume but we want to ensure safety.
09:11And I think Kevin also wanted to
09:12add a few words.
09:14Thank. Thank you, Tracy.
09:17You know, I think like always
09:19we care for cancer patients,
09:21but we are also part of a larger
09:24healthcare system and we play a
09:26pivotal role in function within
09:28that system to ensure capacity not
09:30only for care of cancer patients,
09:33but the entire spectrum of patients
09:36from Connecticut and beyond who require
09:39hospitalization for their illness.
09:41So it is incumbent upon us to
09:45participate as great citizens
09:47and that as we always do,
09:49as we did in the pandemic and
09:51as we continue to do.
09:53And it is hard to overstate the
09:56impact of the current capacity crisis.
09:59I did my first case yesterday
10:01and my second operative case.
10:03The patient was in the pre op
10:05holding area and she was on hold
10:07for about four hours till we can
10:09ensure that there's a bed for her
10:11to go into after the procedure.
10:13So we are at a point where we are
10:16struggling to deliver care to patients
10:18because we don't have the capacity.
10:21I just need to take a minute and under
10:23score the role that we as clinicians,
10:26particularly physicians and senior
10:28APPS and have have in messaging
10:31this to our patients and families,
10:34often our patients who were in
10:36the comfort of a hospital bed.
10:38And I say that relatively have no
10:42idea how profound the hospital
10:44capacity situation is.
10:46And whether they leave at 10
10:49or three or four,
10:50sometimes they don't understand
10:53how significant those few hours
10:56can be and impacting the care of
10:58other patients who were either
10:59waiting for procedures or in the Ed.
11:02So I would encourage all of us to
11:06round early and often and be very
11:09clear in the importance of getting a ride,
11:12communicating with family,
11:14early discharge planning and making
11:17alternative plans to get out of
11:20the hospital in a timely way at
11:22that on the day of discharge.
11:25So that's a hard message for
11:27the nursing staff to deliver.
11:30It's a hard message for the
11:33care management staff.
11:34It is really an area where the
11:36clinicians need to be leading the way.
11:38So I thank all of our teams in advance
11:41for your assistance with this.
11:47So on that sobering note,
11:49I'm going to turn to a more upbeat topic,
11:52which is I am thrilled to announce a
11:57new technology in radiation oncology.
11:59We have Doctor Henry Park with us who
12:02is the radiation oncologist who's the
12:05medical director of our new Reflexion
12:08system that was launched a week or so ago.
12:10And without any further commentary,
12:12I think I'm going to have Doctor Park
12:15tell us about the many benefits that
12:17the therapy has for our patients.
12:22Well, thank you very much.
12:23Can you see my slides?
12:26OK, fantastic. All right.
12:27So thanks very much.
12:29I'm here to talk to you for the
12:31next 5 minutes or so about syntax
12:34biologically guided radiation
12:35therapy also known as BGRT that we
12:38can apply with this new machine
12:40that we have the Reflection X1.
12:41And I I really want to thank everyone
12:43who is who is involved in in in
12:45helping you know over the last
12:46few years get this set up to to to
12:49really this really was a team effort.
12:52Yeah my disclosures including
12:54research funding and consulting
12:56from the company external beam RT
12:58as long as you know is is often
13:00bill it's often given by linear
13:03accelerator that produces high
13:05energy X-rays to treat cancer.
13:07And for each patient we tend
13:09to customize dose delivery and
13:11distribution using some advanced
13:13techniques like IMRT and SBRTI won't
13:15go into the full details of what
13:16that means right now except to say
13:18that it's it's very customized and
13:20really for each patient we're able
13:22to to deliver very high quality
13:23radiation for them with the,
13:25with the,
13:25with the technology that we already have.
13:27This is often guided by daily imaging
13:29before every treatment as well to
13:31be sure that we're really matching what we,
13:33what we think we're doing to what
13:35we're actually giving to the patient.
13:37Some tumors can move substantially
13:39as patients breathe.
13:40So just that as the normal
13:42respiratory motion happens,
13:43especially in the lung and the GI tract,
13:46it's very common for Fatimas to
13:48breathe to move with with every breath.
13:52So the reflection next one is a
13:54novel radiation technology that has
13:56the capability of using the tumor's
13:58own biological PET signal to track
14:01the radiation beams in real time.
14:03This is known as biologically guided
14:05radiation meaning that the tumor
14:07itself serves as as the the honing
14:09device you know for the the radiation by by.
14:12So really as it moves we're able to
14:15to to guide the radiation beams to
14:17follow along as well in real time.
14:20So this is this now is called
14:22Syntex by the company.
14:24This can this machine can also
14:26treat with with standard IMRT and
14:28SBRT as well but really designed
14:29to be able to function to to to
14:32to use the PET signal as well in
14:34order to to do the the BGRT.
14:38So I know there's a lot of acronyms
14:40in radiation oncology but the the
14:42basic idea here is if the red is the
14:44tumor and brown is a target we we we
14:46we can draw out what the tumor is.
14:48But the tumor as you breathe in may move
14:50up and down or left and right or really
14:53any number of directions that we can image.
14:55So that moves and then we we cover the
14:58whole area where the tumor moves in
15:00each for each breath and then we add
15:02a little bit of margin around that to
15:04account for any potential setup errors.
15:06So this at the end is what we
15:08actually treat is the brown.
15:09However with BGRT,
15:10the idea is that you can because
15:13you can track the tumor itself,
15:15you only need that small setup error
15:17margin but not the margin to incorporate
15:19the whole respiratory motion.
15:20So that's why at the end you see
15:22the brown here for BGRT is much
15:25smaller than for the SBRT.
15:26So the idea behind tracking the PET
15:28signal in real time is that we could
15:30decrease the size of the radiation field,
15:32also increase the confidence of
15:34fully hitting our target in case
15:36something changes during the treatment
15:38itself and also to decrease side
15:40the risks of side effects as well.
15:43So that's the really the promise
15:44of this technology is that we'll
15:45be able to do this more and more.
15:48Now as you've may have heard,
15:50we have the 5th Reflection X1
15:52machine in the world here installed
15:54back in April of this past year.
15:56We're the first ones on the East Coast,
15:58the other ones being in Pittsburgh,
16:00in Dallas, Los Angeles and Palo Alto.
16:03And we've also had the fastest ramp
16:05up of the IMRT and SBRT capabilities
16:07of any facility with with using
16:09this machine to really go into to
16:11basically full capacity at this point.
16:13Now we've installed the BGRT
16:15component of this in December.
16:16So just last month the FDA approval for
16:20using BGRT was was given in in February.
16:23So since then all five of the first
16:25five centers have now installed this.
16:27Now we've had a ribbon cutting earlier
16:29this month and are preparing right now
16:31to treat the first patient at Yale who
16:33would be the 4th patient overall in
16:34the world to be treated with this technology.
16:40So indications for reflection
16:41S1 are that the IMRT or SBRT. We really,
16:44really anyone who gets normal radiation,
16:47who gets IMRT or SBRT who needs
16:48some kind of complex radiation
16:50treatment can be on this machine.
16:52There are a few exceptions
16:53that that we we can work out,
16:55but but basically all tumor types are allowed
16:58to get the IMRT or SBRT on this machine.
17:01We also have the for the BGRT that's
17:03that that's for a smaller population.
17:04So only for those with lung or bone lesions,
17:08it could be the primary,
17:09it could be a met,
17:11but has to be treated with five or
17:13fewer fractions with a high dose.
17:14So with the SPRT paradigm,
17:17but just right now in the lung and the bone,
17:19but hopefully eventually will
17:20be for other sites as well.
17:21It has to be hypermetabolic on PET scan
17:23of course to be able to follow the PET
17:25signal and not all tumors are like that.
17:26And eventually the goal and and
17:28one of the reasons we really got
17:29this machine and we're very excited
17:31about this was because of the,
17:32the goal to treat multiple
17:34metastatic sites at once.
17:35We're not quite there yet but they
17:38with with stage 4 cancers of all
17:40types to be able to treat for for
17:42complete metastatic ablation of of
17:43maybe more than all of the metastatic
17:45disease but even potentially
17:47Poly metastatic disease someday.
17:48And if the and and and to be ahead
17:50of the curve in terms of of this
17:53potential indication for for the
17:54use of radiation in that capacity
17:56similar to what we've seen for Gamma
17:58Knife for for brain metastases in
17:59that it used to be very restrictive
18:01to only one or one to four meds.
18:03But now we treat you know we can we
18:05can we often routinely treat more than
18:0710 metastases at once because of the
18:09technology and how it's developed over time.
18:11So we're hoping to also be able to
18:13do this in the body as well and and
18:15and and and really we're in the very
18:17early stages now of of developing this.
18:18But but we're working very closely
18:20with the company to to start simple
18:22and then eventually expand to much
18:24more complicated indications.
18:26From the research side we're
18:27very excited as well.
18:28We just got this perspective registry
18:30called Premier activated through the CTO.
18:33It's a multi institutional perspective
18:35registry that aims to to really to
18:37to study the health related quality
18:38of life primarily but also other
18:40endpoints as well that I've listed here.
18:42And really any patient treated on the
18:45reflection whether it's IMRTSPRT or
18:47this BGRT syntax can really be for
18:50anywhere in the body or they would be
18:52treated anyway can be honest registry
18:54and and and and and and this is going
18:56to be really important to collect
18:57this data over time to to really see the the,
19:00the value of this technology
19:02and then also the potential for
19:04industry sponsored grants as
19:05well. We've recently executed a master
19:07research agreement between Yale University
19:09and Reflection Medical that allows us
19:11to obtain industry sponsored grants and
19:14propose investigated initiated trials.
19:15We've already executed 3 grants that
19:17we've had approved a little while ago.
19:18But now that we have the MRA done,
19:21we are looking forward to to to
19:23executing these grants and to
19:25to actually doing this work.
19:26And we're very excited to be able to
19:28collaborate with nuclear medicine,
19:30with the PET Center,
19:31with medical oncology,
19:32surgical oncology and many others to for for
19:35really innovative research going forward.
19:39So in summary,
19:40this is a very exciting time for
19:41Smilo and a unique opportunity to
19:43be early adopters and researchers
19:44of this novel technology.
19:46Feel free to call me or any of your
19:48friendly Yale radiation oncologist at
19:49any of the sites if you're wondering
19:51if this is right for your patients.
19:53We we certainly will need to do our
19:56legwork to to to figure out if if
19:58your patients may be a candidate.
19:59But we are already getting calls from
20:01all over the country and even from
20:03around the world about this technology.
20:04You know people who live in China and
20:06and have a family member in New York
20:08City who who are interested in if
20:09he heard about this and then want to
20:11hear more and see if they're eligible.
20:13We're always interested in taking those
20:14calls and and hearing more about the
20:16history and seeing if they if they
20:17may be able to to come in and and
20:19people are very willing to fly over
20:21to to to to to have a consultation if
20:23if it seems like it may be appropriate.
20:25So I want to really thank all the Y,
20:26NHH and SMILO leadership as well
20:28as our physicists, asymmetrists,
20:30therapists, nurses, engineers,
20:32administrators, lawyers,
20:34clinical research staff,
20:34residents and attendings and many and
20:36so many others for your your hard
20:38work and collaboration so far in in
20:40getting this program off the ground.
20:44Thank you very much.
20:48Thanks, Henry. That is really it.
20:52I it's hard to overstate the excitement
20:54that I think we all feel and we look
20:57forward to continued updates not
20:59only on the clinical front but and
21:04the research environment as well.
21:10Next up is help me, Renee.
21:15Is it Maddie or is it Man Yee or
21:18is it Doctor Geary? Doctor Gary?
21:23OK, take it away. Doctor Gary.
21:25Lots developing on the genetics front.
21:33Unmute that. OK. Yes, absolutely.
21:36Thank you so much for the opportunity
21:38to come and present for a few minutes.
21:42I hope everyone can hear
21:43me OK and see my slides.
21:45So just in a few minutes I want to run
21:48through some updates for the cancer
21:51genetics and prevention program,
21:53give some idea of the signature of
21:55care pathways that we have built
21:57to help accommodate the patients
21:59that that need genetic testing.
22:01And then really important to
22:03importantly to bring forward some of
22:05the new revisions to our processes
22:07that have had to happen because of
22:09adhering to federal compliance.
22:12So I just thought I would take this
22:15opportunity though to actually show
22:17our cancer genetics and prevention
22:19program back to Smilo and others
22:22here on the on the meeting as
22:24well because it's a real great,
22:25really great team and really
22:27includes a wealth of expertise.
22:30And when we're talking
22:31about genetic testing here,
22:33we're talking about germline genetic
22:35testing and thinking about the hereditary
22:38nature of genetic testing As such,
22:41we have our team of physicians
22:44who are really integral into our
22:48processes for genetic testing,
22:50genetically based management
22:51and high risk care.
22:53With myself and I'm a medical oncologist
22:56and with a specialty in cancer genetics
23:00as well as prostate and Gu cancers,
23:02we have Alan Bale who's been
23:04with the program for many,
23:06many years with the medical genetics
23:08expertise and molecular genetics expertise.
23:10And we're thrilled that we have had
23:13Ellie Prasalaglu who's joined our
23:15team who's a breast surgeon and I
23:17also a trained OBGYN to lead our
23:20breast high risk and genetics efforts.
23:22We have a really terrific team of
23:25genetic counselors that are shown here
23:27with the two lead genetic counselors,
23:29Amanda Ganzak and Claire Healy,
23:30who are the genetics Co managers and they
23:34lead a team of genetic counselors who
23:35see patients across the Smilo network.
23:37So we are seeing patients as you can
23:40see here across the various sites
23:43that are really important in terms of
23:45helping access to care for patients.
23:47We've also recently started a fast
23:49track program and our two genetics
23:51clinical coordinators are shown here,
23:53Carla Cullen Vasquez and Caitlin Shetland.
23:56This is a way to help meet the needs
23:58and I'll talk about this in just a
24:00moment in a more expedited fashion
24:02for genetic testing given the rise
24:03in some indications like precision
24:06medicine and certainly for example
24:08for surgical decision making as well.
24:10We have our genetic counselling
24:12assistants as well who are really
24:13integral to help the genetic
24:15counsellors and the team in terms
24:16of all of the processes that have
24:18to happen for genetic testing.
24:20And then our high risk clinic is with
24:23Sue Smeal who is in APRN and again has
24:25been with our program for a very long
24:28time to see our high risk patients.
24:30So it's a really great team.
24:32Please reach out to any of us at any point.
24:34We love working with the clinical teams.
24:37So the guiding principles for the
24:41processes that we've developed and
24:43you'll see some of the updates are
24:45really ensuring that we adhere to
24:47standard of care for genetic testing
24:49and the practice of genetic evaluation,
24:52ensuring access to care such that
24:54we are able to provide genetic
24:56services across our catchment areas
24:58and in our network and communities
25:01and ensuring that we are adherent
25:03to federal compliance mandates.
25:07So from the physician clinics,
25:09if we look at this flow diagram it
25:12when a patient is identified that
25:13needs to have genetic testing,
25:15there are multiple ways that genetic
25:18testing and genetic evaluation can
25:20be conducted and we've built these
25:23different ways such that it can be
25:25conducive to the needs of the practice.
25:26So for example,
25:27one of the pathways and I'll talk
25:29in more detail about what these are
25:30in just a second would be point
25:32of care where the genetic testing
25:34can be initiated in the provider
25:36practices or it could be through
25:38referral upfront to the cancer
25:40genetics and prevention program.
25:42And we have different referral
25:45processes that are set up.
25:47So those providers that are on EPIC,
25:49whether they're SMILO based providers,
25:51non SMILO based providers,
25:52but also on EPIC,
25:54but also other providers who may not be
25:56on EPIC but who we work very closely
25:59with can also refer to our program.
26:02So the referrals really should be
26:04placed in EPIC if you have EPIC as
26:06are the most sort of the I'll proof
26:08tracking mechanism for referrals
26:09coming to the genetics program.
26:11And once they are in the genetics
26:15program system,
26:16we triage them into either the fast
26:17track program or the genetic counseling
26:19to have a genetic counseling visit.
26:21So let me just talk about that for
26:23just a second and this will then
26:25lead into some of the processes
26:27for adhering to compliance.
26:28So in the genetic evaluation process,
26:31as I mentioned a physician clinics
26:33could have the option to think
26:36about point of care where here the
26:38physician team identifies a patient
26:41that needs genetic testing and
26:43there's really no question about
26:45whether they meet indications.
26:46Here the patient can be shown a
26:48pre test video that we've developed
26:51for the clinical teams and after
26:53the video is seen and patient is
26:55ensured of their understanding of
26:57hereditary cancer genetic testing.
26:59The genetic test is ordered by the
27:01physician team or their staff.
27:03The testing is sent to currently
27:05the Yale DNA Laboratory,
27:06but we're trying to build it out
27:08with additional labs integrated
27:09into EPIC to help ease the ordering
27:12and enhance the testing capability.
27:14Insurance authorization would be
27:16complete completed by the lab or
27:18by the physician's office and then
27:20the patient can be referred on the
27:22back end to Cancer Genetics for
27:24full results disclosure,
27:25particularly if they have a
27:27genetic mutation identified.
27:29But if the clinician team actually prefers
27:31to refer up front to the genetics program,
27:33then what we would do is triage
27:35once we received
27:36the referral to fast track
27:38or to genetic counseling.
27:39The fast track program as they mentioned
27:41is a way to expedite genetic testing
27:43for patients that meet clearly meet
27:45NCCN guidelines for genetic testing.
27:47The volumes of patients that need
27:49genetic testing has risen substantially.
27:51And so we know we have had to
27:54think creatively about how to
27:55address the needs for our patients.
27:57So here the patients are seen by the one
27:59of the genetic clinical coordinators.
28:01They're shown the video genetic
28:04testing is ordered.
28:05Our team completes the insurance
28:07authorization if required and then the
28:09results are disclosed by the genetics
28:11clinical coordinator or a genetic counselor,
28:13certainly by genetic counselor
28:14if there's a mutation.
28:15These results are discussed
28:17within the team itself.
28:18So these genetics clinical coordinators
28:20have the full team input in terms of
28:24results disclosures or we triage the
28:26patient to see a genetic counselor.
28:27And here it's for patients really
28:29that are more complex,
28:31whether it's unclear that they meet
28:33NCCN guidelines for testing or really
28:35mandated to see a genetic counselor
28:37with which some insurances do do.
28:39And then they're seen by
28:40the genetic counselor.
28:41The testing is ordered and the
28:43insurance authorization is conducted
28:45by our team and the results are
28:47disclosed by the genetic counselor.
28:49Now what has transpired over the
28:51past year is a ruling by CMS that
28:54stated that genetic tests must be
28:57ordered by the physician or APP
29:00who is treating and managing the
29:03patient's medical problem or problems.
29:05And they've clearly stated that tests
29:07ordered by a genetic counselor would
29:09not be considered reasonable or
29:12medically necessary per this federal.
29:14So this really you know it,
29:17it is what it is and we've had to
29:20adapt our processes to then meet
29:23the federal compliance mandate.
29:26So based on this,
29:26what we've had to do is point of care
29:29doesn't change of course because
29:30that's happening in the physician
29:32offices who are managing and treating
29:34the patients and the testing is
29:36being ordered by the physician there.
29:38Where the processes had to change was
29:40for fast track and for genetic counseling.
29:42So in this process for
29:44the Fast track program,
29:46these are predominantly internal
29:48to Smilo referring providers.
29:50And So what we have done is set up
29:53processes such that the genetics
29:55team will input information for
29:58genetic test ordering and pend
30:00it in EPIC for the referring Dr.
30:02to sign.
30:02So one thing I'd like everyone
30:04to just please be mindful of it.
30:06In EPIC you're going to start to see
30:09genetic test orders that need to be
30:11signed if you're the referring Dr.
30:13and of course testing cannot
30:15be completed without those,
30:17those sign offs in EPIC.
30:20The other thing we've done is
30:22for the patients that are seen
30:24by a genetic counselor,
30:25these patients can be a kind of in a
30:29multitude of you know referral bases.
30:31And So what we've done is created
30:33different ways that we're handling
30:36this part of the test ordering.
30:37One is our genetics physicians are
30:39seeing many of these patients and
30:41combined visits with the genetic
30:42counselors and then we are signing
30:44off on the genetic test orders.
30:47Another way that we're handling this is
30:49in tandem with our genetics APRN with
30:52SUSHMIL where the genetic counselor
30:54sees the patient first and then Sue
30:56will see the patient and be able to
30:58sign the order for genetic testing.
31:00There are still going to be patients
31:02that need genetic test orders
31:04signed by the referring provider.
31:06So again, this would be where we would
31:09have to upload the result into EPIC and
31:11have the referring provider sign off on it.
31:14If there's a referring
31:15provider who is not on EPIC,
31:16these are patients that we'd be
31:17seeing by the genetics physicians
31:19and we would be signing those orders.
31:21So we've had to develop multiple
31:23processes for signing up orders.
31:24So please keep an eye out in your
31:26EPIC in baskets for these things
31:28coming your way for signature.
31:30One other thing that we have to be
31:32mindful of is that there are certain
31:35insurances that require authorization
31:37for genetic testing to be covered.
31:39Some of these are shown here Tricare
31:41Medicaid and Aetna as some of the key
31:44insurance plans that require insurance
31:46authorization to be completed to pay.
31:49What happened is that those insurance
31:51authorizations form once again have to
31:53be signed by the referring provider.
31:55So for example Medicaid those
31:57signatures have to be fresh signatures.
32:01We can't apply a signature to those
32:04authorization forms on our end.
32:05So we are having to re contact are
32:08the referring doctors to sign these
32:11insurance authorization forms for Medicaid,
32:13for Tricare and Aetna.
32:15We probably are going to be able to
32:17sign the insurance forms if we get
32:19a signature from the referring Dr.
32:22So you're probably some of you are
32:24probably starting to see some emails
32:25coming back saying we need your
32:27signature on this form and or please
32:29provide your signature on a blank piece
32:31of paper and we'll apply it you know
32:34for these insurances to get these authorized.
32:36Obviously this is really time
32:38sensitive for these patients because
32:40otherwise they could get a bill,
32:42you know,
32:42for their genetic testing and it could
32:44be hundreds and hundreds of dollars.
32:45So any way that we can work together to just
32:49start collecting signatures would be huge.
32:53I can talk to Doctor Billingsley,
32:55you know,
32:55at a different point on how to think
32:57about doing this because we obviously
32:58don't want to overburden clinical teams,
33:00but at the same time we have to get these,
33:01you know,
33:02insurance authorizations signed off,
33:04So changes in process,
33:06but all for the sake of patient care.
33:08So you know,
33:09just making sure that we keep
33:10that front of mind.
33:11So we have set up an e-mail specifically
33:16related to this compliance process.
33:18We've sent out one general e-mail already
33:21updating everyone about these processes.
33:23Please e-mail this e-mail if
33:25you have questions.
33:26Of course, you could e-mail me
33:28directly as well and we're going
33:30around to different clinical teams
33:31to give these presentations.
33:33But we do look forward to working with you.
33:35And thank you again for allowing
33:37some time to bring this forward
33:39here for this town Hall. Thank you,
33:45Doctor. Gary, thank you.
33:47I know you and your team have been
33:51working feverishly to bring this
33:53process forward and it just shows how
33:55complicated our work is in a shifting
33:58compliance and regulatory landscape.
34:00I know there are going to be other questions.
34:04You know, I think Renee will be
34:07circulating the e-mail and I know
34:09you will be coming back to meet
34:11with teams as we move forward.
34:14So great work, Manny.
34:16Thank you for joining us.
34:18As always, we are incredibly grateful for
34:22the partnership with our pharmacy colleagues.
34:25I know you're going to be updating us
34:27on early release of medication orders.
34:28So I think in the interest of
34:31time press ahead.
34:32Yes, I will share my screen.
34:37OK everyone thank you for having me here
34:41to share the early release of medication
34:44procedure few before the holiday.
34:47There's an e-mail had sent out to share
34:51everybody about early release process.
34:55Sorry I cannot advance my slides.
35:01OK, here we go.
35:03Yeah. So few weeks ago
35:04we have shared the emails to communicate the
35:07early release standard operation procedure.
35:11This early release SOP is not new and and
35:14in fact has been implemented since 2013.
35:18We just share with everybody with the update
35:21and but we take the opportunity here to
35:25reiterate this topic and we talk about why
35:28we need early release and how does it work.
35:31And as you can see this graph,
35:34it's clearly illustrated that there
35:36is influx order coming through
35:38within a short period of time.
35:40So maturity order for the of the
35:42day comes in within three hours.
35:45So this can lead to a in efficient workflow
35:48and prolonged patient waiting time.
35:54The benefit of the early release process
35:57has been shown in other Cancer Center
35:59to it can reduce patient wait time,
36:02improve workflow and patient experience
36:05more importantly can help us to
36:08improve infusion chair utilization.
36:11So we since we have implemented this
36:15SOP actually other cancer centre have
36:17reached out to us over the years
36:20to share our experience and also
36:22get a copy of our SOP to implement
36:25it to their cancer there too.
36:27So in general medication selected
36:29for early release,
36:31it's considered as IV administrator
36:33supportive care medications
36:35such as pre medication,
36:37anti medic hydration medication with
36:40independent laboratory results such
36:43as Tritusumab treatment regimen
36:46containing consecutive treatment
36:48days such as epoch days 2 to 4,
36:52etoposides days 2:00 to 3:00.
36:57So how does it work and this is
36:59how we work that work for during
37:02the proceeding treatment day,
37:04nurses and pharmacists in the
37:06clinic will collaborate to
37:07determine appropriate medication
37:09for early release by reviewing
37:11the next treatment day schedule.
37:13The nurse performs independent
37:15review and release the medication.
37:18The pharmacist perform independent
37:20review and verify the medication.
37:23Then the pharmacy will prepare
37:25the medication in advance with the
37:28consideration of drug stability
37:30and cost on the treatment day prior
37:33to administration that a different
37:35infusion nurse will perform a second
37:38review in addition to confirm with
37:40the provider the plan to treat so.
37:43As you can tell all these procedure
37:46has not changed any of the standard
37:49steps that for safety check.
37:51So but it's to shift the some of
37:53the work the day before to allow
37:55the medication to be ready before
37:58the patient come into treatment.
38:02So we'll leave to any question.
38:09Thank you, Manny.
38:10I think there will likely be
38:12some questions in our Q&amp;A.
38:14So I'm going to defer until that
38:18time like Doctor Gary's presentation,
38:20this is incredibly important and I'm
38:23hoping that you and your team mates
38:26will kind of make the rounds among the teens.
38:29I'll just share from my perspective
38:31there are a few things that we can
38:34do that will improve patient and
38:36nursing staff in few experience in
38:38the infusion centers more than the
38:41ability to get drugs to patients
38:43quickly when they get in their chairs.
38:46So this isn't really valuable work.
38:50So more to come next.
38:53Maddie Kaler has done amazing work
38:56with her team over the past year
38:59since she's been in this role,
39:02building our portfolio of supportive
39:05services including integrative medicine,
39:07Reiki, nutrition,
39:08a variety of things which enhance the
39:12quality of life and experience for
39:14patients along their care journey.
39:17So Maddie's joined us today to
39:19give us a variety of updates.
39:21Thank you.
39:26All right. Thank you for having me.
39:28I'm very excited to speak with you about
39:31the supportive care program here at Smilo.
39:34And I have been leading this team
39:36with my clinical colleagues,
39:38Doctor Jennifer Capo and
39:41Executive leadership Sonia Gross.
39:42Also, I'm very excited to speak
39:44with you about the the team.
39:46So first and foremost, just a little bit
39:49of some background on supportive care.
39:51The multinational association of
39:53supportive care and cancer defines
39:56supportive care as the prevention
39:58and management of the adverse
40:00effects of cancer in its treatment.
40:02This definition does include the
40:04management of physical and psychological
40:06symptoms and side effects across the
40:09continuum of the cancer journey.
40:11Which is really excited,
40:12really exciting that they define the
40:14whole continuum of cancer care because
40:17that's exactly what our team does and
40:19I'm very excited to kind of speak with
40:21you a little bit more about it today,
40:23kind of tapping into the
40:25history of supportive care.
40:26Supportive care really became kind
40:29of well known kind of in the 1960s
40:32and seventeen 1960s and 70s when
40:36chemotherapy became more widely
40:38used in oncology treatment and it
40:41really focused really in the the
40:44medical side effects of cancer.
40:46And over time we've actually opened
40:48up that definition to include a
40:50lot of different facets as we look
40:52at whole patient care.
40:54We're taking into account now
40:56the emotional well-being,
40:57the psychosocial well-being,
40:59the spiritual health and the
41:01physical health of the patient.
41:03So supportive care is really
41:05encompassing all of these facets of
41:08of cancer care in oncology patients.
41:10So in research supportive care,
41:13effective supportive care has actually
41:14been seen to improve the quality of life,
41:18decrease the symptom burden and then
41:22increase survival, increase survival.
41:24And then as it relates to
41:27hospital operations,
41:28effective supportive care has also been
41:30seen to decrease hospital admissions and
41:33decrease emergency department visits.
41:35So in aligning that with some
41:38of the surge issues that we are
41:41now seeing at the hospital,
41:43it really is you know holistically
41:45looking at the the whole patient
41:47and in preventative care as well.
41:49So we were fortunate enough to
41:52receive a grant from the Milbank
41:54Foundation to launch a supportive
41:57care access program here at Smilo.
41:59And this program has now been
42:01live for about a year and a half,
42:03two years now and we are extremely
42:06excited to partner with our
42:08clinical colleagues in making this
42:10team come a reality.
42:12So the supportive care team
42:14is a team of lay navigators.
42:16So it's non clinical navigators that
42:19really conduct phone screenings with
42:22patients as they complete their new
42:24patient visit here at Smilo and
42:26assess where they're at and kind of
42:29understand if they have any needs
42:31that we can potentially meet with our
42:34supportive programs that we have here.
42:37So on this screen you can see that
42:39patients that can actually come to
42:41us in two different ways and that's
42:44they themselves can self refer to
42:46us or where where you all come
42:48in in partnership with us is
42:51that our clinical teams can refer to
42:54us in EPIC which is super important.
42:57So we conduct phone screenings
42:59with patients and then we assess
43:01for eligibility for 15 programs.
43:04We have here at Smilo that you can
43:06see on the lower half of the of the
43:09screen and we will refer to these
43:11teams accordingly if patient's
43:13needs align with eligibility and
43:15criteria for all of those 15 teams.
43:18And what this does is not only
43:20does it meet the patient's needs,
43:22but it also does increase the
43:24utilization of our wonderful supportive
43:26care programs that we have here.
43:28I think it's important to note that a
43:30lot of the patients didn't know that we
43:32had some of these supportive care programs.
43:34So it really is a great means to
43:37to advocate for these programs and
43:39actually help increase the education
43:41for patients on the supportive
43:44care programs that we do have here.
43:46So when you refer to us in EPIC,
43:50you can refer to us in two different ways.
43:52We've made it easy so you can find
43:55us in a smart set as I've outlined
43:57on this screen and this,
43:59This smart set is available in the Smilo
44:02Supportive Care Referrals smart set.
44:04So we're an easy check box for you,
44:08but you can also find us when
44:10you type in Smilo Supportive Care
44:12referral services as well.
44:14And this actually is a very important
44:16way that you can get your patients
44:19in touch with with us because
44:21this serves as the starting point
44:23for our contact with patients.
44:25When we reach out to patients usually
44:27at the onset of their diagnosis,
44:30we're not really expecting them to
44:31be open minded or interested in any
44:33any of the supportive care programs
44:35at that point because we understand
44:37that they may be overwhelmed with
44:40a new oncology diagnosis.
44:42However, when we usually talk with patients,
44:44we give them the option for a later
44:47call back and we've noticed that
44:49you know two months in three months
44:51into their oncology treatment,
44:53they really are more open minded
44:55understanding and it will actually
44:58accept referrals as they are
45:00encountering different challenges
45:01along their cancer treatment journey.
45:04So the referral and EPIC from you
45:05all is really a great starting point
45:07for a relationship that we have
45:09with the patient throughout their
45:10continuum of their treatment plan.
45:12So your I can't under site that enough
45:15that truly the partnership with our
45:17clinical teams is very important
45:19in making sure that patients have
45:21what they need from an outpatient
45:23perspective throughout the whole
45:26duration of their oncology treatment.
45:29So we are located on site.
45:31For those of you who are interested or
45:35in the area or would like to stop by,
45:37we are located in the Patient and
45:40Family Resource Center on NP1.
45:42Our doors open Monday through Friday,
45:448:00 to 4:30.
45:45I encourage you to come on in our great
45:48supportive Care Referral Coordinator.
45:50Her name is Solitaire Adorno
45:52and she is a wealth
45:53of information for all
45:55things supportive care.
45:56So if you have patients who are
45:58interested in learning a little bit
46:00about everything, our door is open.
46:01If you yourself would like to learn anything
46:04about the supportive care programs,
46:06the Patient Family Resource Center
46:08is a good first place to stop by.
46:10We have a wealth of resources
46:12both written and and and printed
46:15material for you all to take
46:17and and read at your leisure.
46:20But we're we also do have a centralized
46:23phone and e-mail address so that's
46:25how patients find us usually.
46:28We do have rack cards.
46:29So for any of your clinics or areas
46:31if you would like our information,
46:32I would be happy to send you
46:35interoffice use some rack cards.
46:37But we also do have an online
46:38website too where it highlights a
46:39little bit about about our teams,
46:41but it also goes and takes a deeper
46:43dive into the 15 teams that we
46:45are fortunate enough to support.
46:47So thank you all for your partnership
46:49so far and this team is growing
46:52and we're really excited to partner
46:55with all of our clinical colleagues
46:57across all disease disk plans and
46:59continue to educate patients and
47:01put them in touch with the with
47:04the supportive care programs here.
47:06So with that I'm open for any questions.
47:11Maddie,
47:11there is a couple questions in the chat,
47:13one for clarification on
47:15what patients are covered.
47:17It seems that someone's asking about
47:20Bridgeport in particular and the other is
47:23in relation to a financial counseling.
47:25Is there any of these services that
47:27provide any financial counseling?
47:31Yeah, so our financial or our
47:33supportive care resources,
47:34we have completed our financial assistance
47:38kind of how TOS and things of that sort.
47:41So we do have a partnership with
47:42our finance and billing office.
47:44So for patients who are inquiring about
47:46payment plans and things like that,
47:48we can definitely put them in touch
47:51with with our colleagues in the SBO.
47:53I should say we are eligible
47:55for all patients of Smilo that's
47:57across the Smilo network,
47:59across all Smilo, SMILO sites as well.
48:03Everyone can utilize us.
48:10I think there's one other
48:13question from Paula.
48:15Thank you, Paula. She asked Mehdi,
48:18within the 15 services available to
48:20our SMILO patients, is there any,
48:22did we cover this financial counseling?
48:24Yes. OK, thank you.
48:28Could I ask doctor Gary one question?
48:36What,
48:40how, how can our referring physicians
48:46is there anything we can do or the APPS
48:49can do to engage with payers up front
48:55or early on so that you and your team
48:59are not doing as much back end work.
49:03Is there any kind of, in other words,
49:07preemptive documentation that we
49:10can be submitting with the with the
49:13order to to kind of short circuit
49:17the review process so it becomes
49:20so it's less laborious? Yeah,
49:22no, it's a really great question.
49:24I mean that's what we've been
49:28thinking about to be truthful.
49:31It's a subset of the patients that
49:33have genetic testing ordered that
49:35need those authorizations done.
49:37You know it's not all of them,
49:39the laboratories are the ones
49:41that submit to insurances, right.
49:44So it's happening kind of outside
49:45of our domain for coverage of the
49:49cost for right now it's those
49:51kind of three big insurance plan.
49:52I think what would help us the most
49:54is if we could collect signatures,
49:58it seems like that's a laborious process.
50:01But if we could connect with say
50:03clinic nurses or other clinical staff
50:05who could garner the signatures for
50:08us of the physicians in that team,
50:10that would be a huge help to us because
50:14it is a subset of the patients that when
50:15it arises it's like suddenly time sensitive,
50:17you know, so that way we could,
50:21we could just go forward, you know,
50:22so that's one thing we've been trying to do.
50:25So if there's a way to collect that
50:27information of who are the key individuals
50:29per clinic for us to connect with,
50:31that would be a really,
50:33really helpful thing for us And then we
50:35would be able to make make those links,
50:36get those signatures and
50:37have them on our files,
50:39you know, to do that.
50:40Aside from that,
50:41I can ask our, you know,
50:43lead genetic counselors as well to
50:44your more directly to your question,
50:46if there's other ways around it.
50:50That's helpful. Thank you.
50:51I think we can work on those things.
51:04No, I I'm going to take moderator's privilege
51:08and ask one other question. Doctor Park,
51:16we refer as clinicians, you know a host
51:19of different patients to the department.
51:25Is it is it at all helpful if we
51:29ask specifically for biologic
51:30guided radiation therapy,
51:32if we're if we think it may be helpful
51:35or do we just leave it to you and
51:37your team to to really decide what
51:40patients would be most appropriately
51:42treated with that therapy? Yeah,
51:45that's a very good question.
51:46You know there are a lot of
51:47restrictions at least at this point
51:49in terms of who's eligible or not.
51:50So certainly if you would
51:51like to bring it up there,
51:53you're more than welcome to ask about that.
51:55When you're making a referral
51:56or the to call the person that
51:58you that you're referring to,
51:59just ask about it.
52:01But at the same time,
52:02you know there's a lot of legwork
52:03on our end that sometimes we
52:05don't know right up front either.
52:06Sometimes we can make a determination
52:08based on what's available already,
52:09but sometimes we we do need to go
52:10through the process a little bit
52:12in terms of some of the imaging
52:13only sessions and some other the
52:15the simulation sessions to to
52:16model things before we really
52:17know if they're eligible.
52:18So I think the important thing
52:20is when you're referring to not
52:22necessarily promise the patient that
52:23they will be getting BGRT since many
52:26of them won't actually be eligible.
52:28But that being said,
52:29if you'd like to to to to mention
52:31that this may be a possibility
52:32for them without promising it,
52:34that certainly could be helpful.
52:38Terrific.
52:46Let me just make sure we're not
52:48missing any questions. I think we,
52:53we do have some follow up work to do
52:56with Bridgeport Hospital and I think
52:59we've covered a lot of territory.
53:02Thank you to all of our panelists.
53:04Tracy, is there anything I've missed?
53:07Do you any, any closing comments or
53:09things to add we could maybe give
53:11people a few minutes back this evening.
53:14I'm sure they would appreciate that.
53:15No, I I just want to thank
53:16everyone for their time.
53:17I think these were great topics
53:19and you know hopefully we'd also
53:21like to ask if people have things
53:23that they would like to hear about,
53:25please you know e-mail Kevin or myself
53:26or Lori or Eric and let us know.
53:28We really want to make this engaging
53:30and useful to the participants,
53:32so we'd be happy to hear your
53:34feedback on that as well.
53:39And Tracy, if I could just add to
53:41that because we've talked about
53:43this recently topics, but also
53:46we know that it's hard to find any
53:49great time that works for everybody.
53:51So we would love to get
53:53feedback on other ways
53:55in which we can
53:58reach folks
54:00to to to
54:01be able to generate as much
54:04involvement engagement as as
54:05possible. We do record these
54:08and would strongly
54:09encourage that you encourage your teams,
54:12your colleagues to take the time
54:15to go in and and look at
54:17what's been discussed
54:18because it's there is a lot of really
54:20important information that is shared and
54:23we certainly experienced that this
54:26evening. So that would be another
54:28area that would be of interest
54:30for us to hear about.
54:38Thank you everyone.
54:39Have a great evening.
54:41We appreciate all you do.
54:44Thank you. Bye, bye.