In-Home Infusions Could Continue to Bridge Disparities in Cancer Care

Chevon M. Rariy, MD

A silver lining of the COVID-19 pandemic has been the rapid uptake of telemedicine and virtual health care for patients with cancer, said Chevon M. Rariy, MD, who added that in a post–pandemic state, the potential for in-home infusions could further bridge gaps in access to care for patients being treated with chemotherapy.

“I oversee our telehealth program for CTCA [Cancer Treatment Centers of America], and I consider myself sitting between the intersection of clinical care delivery and technology. It’s been exciting to be able to bring care to patients when they need it most and see how it’s beneficial to them,” said Rariy.

“We can appreciate that a slight delay in treatment might [have been] appropriate for the peak of the pandemic, but when [treatment] is delayed for months, the mortality rate can be affected. [Delayed treatment] can also affect how patients are experiencing symptoms and survival. By moving certain chemotherapy agents and infusions into the home, it could provide an opportunity to continue necessary treatment in a safe manner,” added Rariy.

In 2021, CTCA announced that they were partnering with Coram, CVS Health’s infusion care business, to deliver in-home chemotherapy infusions to eligible patients. Currently, the pilot program is enrolling Atlanta-based patients with a range of diseases, including breast, lung, prostate, colorectal, head and neck, and some genitourinary cancers, but is planned for expansion to other parts of the United States, Rariy explained.

In an interview with OncLive, Rariy, director of the Telehealth Program at CTCA, discussed how the implementation of telehealth during the COVID-19 pandemic shed light on the need for increased access to care for patients with cancer, as well as the potential benefits in-home infusions could offer to patients receiving chemotherapy.

OncLive: How has the expansion of telehealth mitigated some of the challenges that arose during the COVID-19 pandemic?

Rariy: I’ve been in the telehealth space for over a decade, so it has been the silver lining [of the COVID-19 pandemic] to see telehealth [become] a powerful tool. The COVID-19 pandemic [emphasized that telehealth] is a powerful patient-first [tool]. Quite frankly, [telehealth] has allowed us to supercharge the American health care system. It’s propelled us into transforming health care delivery and allowed for the reimagining of how care is delivered, which is very exciting.

Before the pandemic, telehealth services were not used significantly in cancer care. Now, as we can appreciate it, it certainly has significant use. With the proliferation of telehealth appointments during the pandemic, the approach and expectations of the providers and patients have changed. Providers feel encouraged and see [telehealth] as feasible. It is helping to improve outcomes.

During the pandemic, virtual care helped to bridge the gap [in care], allowing us to continue to treat our patients. I always like to say that in the telehealth-oncology [realm], the virtual visit will never replace in-person care. [That] is extremely important when a physical exam is needed or when additional labs, imaging, or procedures are required. However, it can play a very critical role in augmenting [patients’] visits and in health care moving forward.

To give just a few specific examples, the virtual health visit within oncology can be a way to quickly assess symptoms, help with symptom management, help manage pain or chronic disease, review imaging or lab [results], and discuss treatment options or treatment concerns. A number of our surgical partners are using telehealth for preoperative or postoperative procedure discussions. Second opinion consultations, genetic counseling, and clinical enrollment can be done through telehealth. The list is long and extensive [of things we can accomplish with telehealth].

What patient populations stand to benefit from in-home infusions?

At CTCA, we engage in a partnership program with CVS and Coram to provide chemotherapy in the home with remote patient monitoring and telehealth oversight with our providers. This was an opportunity to extend care beyond the brick and mortar.

Eligible patients include those with breast, lung, prostate, head and neck, and colorectal cancers, just to name a few. Eligible patients needed to be relatively healthy in order to have chemotherapy in the home. The sicker patients need that high-acuity hospital setting.

It’s extremely important that we had very specific eligibility criteria because safety is of paramount importance. Part of that is making sure a patient can tolerate the infusion before moving into the home. We advocate for at least 1 to any number of infusions to be given in the hospital or an outpatient care center with higher acuity eyes in case the patient has an allergic reaction or something that would deem them [ineligible] for [home administration].

Once patients have the infusion and they are deemed appropriate to move into the home, we look at enrolling them into the program. It is often in the maintenance phase [that patients are eligible].

What criteria constitute a suitable environment for in-home infusions?

[We look for] a number of things. We want the environment to be hygienic. Running water is a basic requirement, but it’s important. If there were something that needed to be cleaned up, we want to make sure the home nurse has access to those appliances. We need to make sure there is a place where the patient can get the infusion or injection for the designated amount of time in an isolated place without having animals, like dogs or cats, run around. There should be an area to put pets in behind closed doors. [We also look to see that] children are not in the home when the infusion takes place or whether there is an area the parent [can] receive treatment in. The environment [must be] safe for our nurse as well.

Have any data shed light on the need for an in-home infusion treatment approach?

When we look at the specific data in a pre–COVID-19 state, the typical oncologist [was seeing] about 94 patients per week. At the peak of the pandemic, [that number] was down to about 46 patients per week. Now, we have rebounded and seen some improvement, but it has not gone back to a pre–COVID-19 time. Providers are [still] not seeing as many patients as they did prior to COVID-19, so it is about 74 patients per week now compared with 94.

Care being delayed is a very big problem that we certainly worry about. Screening is not happening [with the same frequency], treatment is being delayed, and clinic appointments are being delayed, so when the patients do come to the clinic, they [can present with] later-stage cancer or more virulent disease that is difficult to treat.

Those are all things that we worry about as it relates to home infusions, [but highlights] the benefit they can provide. If the patient qualifies, home infusions can simply allow the patient to continue their care within the comfort and safety of their home. Patients with cancer are already immunocompromised, so to put them in a larger, hospital-based environment where the COVID-19 virus is more rampant is problematic. [Home infusions] are an opportunity where we can move the appropriate care into the home to benefit the patient.

What lessons were learned from the COVID-19 pandemic that highlight the need for increased access to care among patients with cancer?

Telehealth has had enormous effects [already], but it has enormous potential to provide access to health care. There is no magic bullet for increasing access to health care across many different walks of life, but [telehealth] is certainly a step in the right direction. With that, the pandemic has shone an important light on a number of biases within the health care system, [including] racial bias and urban vs rural–based bias. [The pandemic] has allowed us to appreciate what types of care and considerations need to take place to be able to reach patients where they are at.

As we are looking at the future of telehealth, there are a number of lessons we can take with us. First and foremost, [we learned] that consumers want greater control of their health care interactions. How can we utilize virtual health or digital health management applications? How can we utilize integration with wearable applications or shorter wait times—all of the conveniences that we have seen with virtual health—to really empower the patient?

Patient experience matters. We have an elevated patient experience, and they want greater personalization. [Telehealth] is one way that we can help to make that happen.

[Additionally], a multicultural approach is important and significant, especially in the cancer space where we see significant variations in outcomes for populations. Black American women are significantly more likely to die from breast cancer vs others, so that is a gap that we can look to close.

We can use [telehealth] as one tool in our arsenal. Those patients who live in underserved, rural communities die at higher rates vs those who live in urban-based communities for the same disease. How can we provide access to quality care for our rural Americans? How can we leverage virtual health to be able to do that?

How could a patient become part of the collaboration between CTCA and CVS Health to potentially receive in-home infusions?

Right now, we are offering this as a pilot program in the Atlanta-based market alone with plans to expand it with time. Right now, it is for CTCA Atlanta–based patients. It is a way for [patients]—once they are deemed eligible by their clinical staff, home assessment, and the medications that they are on—to consider moving their treatment into the home.

If there is an interest from a patient’s perspective for such a program, we do have individuals in our Atlanta-based site who can provide [more] information. We are partnering with CVS and Coram. We’ve helped with training the nurses to make sure they are provided with appropriate oncology-based chemotherapy training and have the standards of care when moving to the home. They are a nationally based program that covers about 97% of the United States population.

What should providers know about the collaboration if they have a patient who might be eligible?

Safety is of paramount importance. Not all patients can move to the home. Not all providers can wave a magic wand and move [their patients’ infusions] to the home. This was a very long implementation process that was thought through because of safety, the nature of these patients, and the nature of the program. By providing remote patient monitoring, [we can assess] vital signs on a continuous basis and access the patient’s medical oncologist through telehealth. That has provided the opportunity to have those safety nets. If a provider is interested, the safety of the patient needs to be at the core of any type of program development.

Does the cost of in-home infusions differ from infusions done in a clinical setting?

Patients don’t see a huge difference in cost, but it certainly was in discussion with the payers. Right now, we have alignment with a few payers, and we need that alignment before [patients move to in-home infusions]. Not all patients may be eligible for the program; it depends on their insurance carrier.

There are a number of payers that, quite frankly, are instituting that some chemotherapy agents be mandated in a lower cost of care setting, [meaning] not in the hospital. In this situation, the home meets those criteria.

What is your hope for the future of telemedicine and access to care post–COVID-19?

As we’ve been moving into virtual care, these are important learnings that we have been able to garner. Certainly, virtual care has had a lot of time in a pre–pandemic state. The [United States Department of Veterans Affairs] was involved heavily in telehealth, telemedicine, and virtual care since the 1960s, so a lot of learnings have been garnered over time. It’s been the relaxation of federal and state regulations more recently that has allowed telehealth and virtual care to shine and show that there is so much more that can be garnered here. [Telehealth] has been the beacon of hope to so many in need during the pandemic. Of course, we are hoping to make the case that a lot of the waivers that were put in place should be made permanent to continue [providing] access to these programs in a post-pandemic state.

Reference

1. CVS Health collaborates with Cancer Treatment Centers of America to provide in-home chemotherapy. News release. CVS Health. January 12, 2021. Accessed July 6, 2021. https://bit.ly/3xkv1Dq.