Cancer Care @ Home

Safe, efficient, life-extending care in the comfort of home

Opportunity

Each year, about 1.8 million Americans are diagnosed with cancer. Historically, nearly all life-extending cancer treatment has been delivered in outpatient or hospital settings. Within a year of diagnosis, three-quarters of those with advanced cancer end up in the hospital; one in six are hospitalized three or more times. And nearly all chemotherapy is delivered in physician offices or outpatient clinics. Patients have to travel in, pay for parking, and spend hours waiting for and receiving care.

Internationally, giving cancer drugs at home has been done safely and effectively across various patient populations and treatment regimens. But it’s uncommon in the United States.

At Penn Medicine, we provide world-class cancer care to more than 26,000 new patients each year. In late 2019, a multidisciplinary team of experts, brought together by the Penn Center for Cancer Care Innovation, began to explore if home cancer treatment could, for appropriate drugs and patient populations, take the place of inpatient or outpatient administration.

Intervention

Cancer care @ home (CC@H) is an evidence-based, patient-centered program that enables life-extending cancer treatment to be delivered in the home.

The program proactively identifies optimal candidates based on specific criteria agreed upon by clinical teams. Providers discuss CC@H with their patients during telehealth or in-person visits and prescribe home treatment using the electronic health record (EHR).

From there, staff from Penn Home Infusion Therapy (PHIT) obtain insurance authorization, discuss out of pocket cost with patients, and schedule home visits. A courier delivers the medication to the patient’s home, and an oncology-certified nurse arrives on the day of the scheduled visit to administer care. Throughout this process, the prescribing oncologist monitors the patient’s treatments to ensure coordinated care.

Impact

Since CC@H launched in February of 2020, hundreds of patients with breast cancer, prostate cancer, and lymphoma have received timely, safe, and effective treatment in the comfort of their homes. The program is now a standard of care at the Abramson Cancer Center.  

CC@H patients report dramatically increased satisfaction with care, enhanced convenience and comfort, and a better overall health care experience. With CC@H, patients with lymphoma can spend 25 fewer days in the hospital, and patients with breast or prostate cancer can have up to 12 fewer outpatient visits a year.

Providers are excited to be able to offer CC@H as an option for their patients. And for the health system, CC@H increases capacity while maintaining timely and effective care.

The team is exploring opportunities to make CC@H available for more patients.

COVID-19

CC@H strengthens the health system’s pandemic response by decreasing infusion suite density and increasing inpatient bed capacity. Redirecting immunocompromised patients from the clinic or hospital to receive their cancer treatment at home protects these vulnerable patients from unnecessary exposure.

The COVID-19 pandemic added great urgency to CC@H efforts. When stay-at-home orders were issued, the program scaled quickly. Over seven weeks, CC@H saw a 700 percent increase in the number of patients participating.

Phase 3: How we work
Collaborators

Penn Center for Cancer Care Innovation

  • Callie Scott, MSc
  • Amy Laughlin, MD
  • Justin Bekelman, MD

Abramson Cancer Center

  • Jenn Braun, MHA, RN, BSN
  • Pat Higgins, MHA
  • Lindsey Zinck, RN, MSN, OCN
  • Larry Shulman, MD
  • David Miller, MBA
  • Bob Vonderheide, MD, DPhil

Hospital of the University of Pennsylvania

  • Donna Capozzi, PharmD
  • Lu Ann Brady, MS

Penn Medicine at Home and Penn Home Infusion Therapy

  • Sandra Jost, PhD, RN
  • Sarah Johnson, MBA
  • Mary Denno, MSN, RN
  • Cassandra Redmond, PharmD, MBA
  • Katherine Major, MSN, RN, CPHN
  • Joan Doyle, RN, MSN, MBA

University of Pennsylvania Health System

  • Neil Crimins
  • Robert Tobin
  • Roy Schwartz, MBA

Division of Hematology and Oncology

  • Suzanne McGettigan, MSN, CRNP, AOCN
  • Dan Landsburg, MD
  • Roger Cohen, MD
  • David Vaughn, MD
  • Lynn Schuchter, MD
Innovation leads

Mike Begley, MA
Tim Delaney
Shivan Mehta, MD, MBA, MSHP

Funding

Penn Center for Cancer Care Innovation
Innovation Accelerator Program

Innovation Methods

A day in the life

One of the best ways to learn more about a problem area is to experience it yourself. Immerse yourself in the physical environment of your user.

Do the things they are required to do to gain a firsthand experience of the challenges they face. Completing a day in the life exercise will enable you to uncover actionable insights and build empathy for the people you're hoping to help.

A day in the life

The CC@H team performed contextual inquiry by observing PHIT nurses on home visits.

This afforded a deep, contextualized understanding of the existing workflows and provided insight into how cancer care delivery could be integrated into the team’s suite of available therapies.
The concierge
A concierge provides hands-on, efficient, and proactive services for customers.
 
Similar to the concept of walking in someone's shoes, a concierge walks alongside someone and helps them get things done.
 
Acting as a concierge or high-touch helper for a small sample of people will enable you to get deep into the reality of their journey and learn about the barriers they face, because like a real concierge, you'll help them navigate those barriers. You can also test solutions in real time as you explore the problem space in context.
The concierge

During early pilots, patients had access to a 24/7 concierge service. Patients could call in with questions and concerns at any time.

This helped the team identify attributes of the pilot program that could be improved as well as validate what was working - insights that shaped the final design of the program.

Commentary

Scaling the program

During initial contextual inquiry with patients, family caregivers, and clinicians, we noted that participants with no previous home treatment experience held decision-making biases favoring outpatient or inpatient settings. For patients, these included safety concerns and deference to their doctors’ recommendations. Physicians also had concerns about safety and the potential for increased clinical care team burden and difficulty in ordering and tracking cancer care at home. We assessed these concerns as representing three major barriers to cancer care at home.

  1. Status quo bias
  2. Therapeutic norm bias
  3. Friction costs

We applied insights from behavioral economics to design workflows for cancer drug delivery at home that systematically addressed these barriers. To counter therapeutic norm bias, the team identified optimal candidates for cancer care at home proactively, based on criteria agreed upon with the clinical teams. To counter status quo bias, we set home treatment as the default for patients meeting the agreed-upon clinical criteria, with the option for clinicians or patients to opt-out. To address safety concerns, we educated physicians and patients about the safety standards patients would experience at home, comparable to those experienced in the clinical setting, including the Oncology Nursing Society certification of all participating nurses. To minimize friction costs during the process of shifting treatment from inpatient or outpatient settings to home, the CC@H team took on as much of the work as possible, including calling patients, preparing drug orders, scheduling visits, documenting updates in the EHR, and handling patient calls about medical issues. With this approach, we could test small changes to reduce friction and understand the constraints and resources necessary to scale the program.

Videos

Stories of Innovation - Cancer Care at Home