The COVID-19 pandemic has accelerated changes in our technologies and processes, making it more important than ever to reach our patients where they are. From ramping up our telemedicine practice to expanding at-home care offerings, our primary focus continues to be providing the best possible care to patients while keeping them and our staff safe.
To better understand how the pandemic is transforming Penn Medicine’s approach to patient care, we spoke with Justin Bekelman, MD, of the Penn Center for Cancer Care Innovation and Carmen Guerra, MD, MSCE, FACP, the Abramson Cancer Center’s Director of Diversity and Outreach. Read their thoughts on how cancer care has evolved and what to expect in the future.
Prior to the COVID-19 pandemic, how were telemedicine and home care options leveraged for cancer patients?
Dr. Guerra: Penn Medicine opened one of the country’s first teleICU programs over a decade ago. We’ve been a long-time leader in telemedicine to support advanced inpatient care. However, prior to the pandemic, it was not common for cancer patients to have telemedicine appointments with their providers.
Dr. Bekelman: In 2018, through a landscape review and horizon scanning, we began to identify ways that we could improve patient experience and reduce unplanned acute care—hospitalizations and emergency department visits—for patients with cancer. Inspired by how telemedicine dramatically changed how primary care is delivered, we believed we could achieve equal or higher quality care, greater patient satisfaction, and lower cost by delivering cancer care at home.
And, Dr. Bekelman, you had launched a demonstration program for home cancer care in February. How was that program affected by the outbreak of COVID-19?
Dr. Bekelman: Cancer Care at Home, which is a joint initiative of PC3I, the Center for Healthcare Innovation, the Division of Hematology and Oncology, and Penn Medicine at Home, offers patients the services of a multidisciplinary care team and access to more than a dozen cancer drugs. The emergence of COVID-19 caused the number of participants to skyrocket because, for some patients, it was safer to stay home rather than come into the hospital for treatment.
Once it became clear that we needed to decrease density in the hospital and infusion clinics to have capacity for patient needs during the pandemic in the spring, we had to scale the program quickly. By June, we had referred more than 400 patients to receive care at home.
What were some of the logistical challenges in making such a strong and sudden shift to telemedicine and at-home care?
Dr. Bekelman: As a start, not all cancer drugs can be administered in a home setting and not all patients are appropriate for at-home care, so we established selection criteria to maintain the highest possible safety and quality.
We worked with physicians to appreciate their challenges with prescribing cancer drugs at home and ensuring they could monitor their patients’ treatments. And our great people—truly heroes—like our oncology infusion clinic nurses volunteered to redeploy in this new setting, delivering cancer treatment at home to their patients as we ramped up capacity. We benefited from our preparedness and the expertise of our team here at Penn Medicine.
We also had to be mindful of insurer’s reimbursement policies because receiving treatment in different sites of care can impact payment to providers and out-of-pocket expenses for patients. Going forward, there needs to be new rules to appropriately pay for cancer care at home, including policy that lets patients with cancer receive acute care and infused cancer drugs at home. Insurance companies should promote—or at least not obstruct—delivery of cancer care that’s more patient-centric.
Dr. Guerra: That final point is very important; a potential barrier to care was lifted when insurers agreed to cover telemedicine appointments.
And what were the particular considerations — for example, access to broadband at home — for patients in traditionally underserved communities? How would you compare their access to care before and during the pandemic?
Dr. Guerra: Telemedicine and broadband internet are unaffordable or inaccessible for many people. In Philadelphia alone, according to the census, 26 percent of residents do not have access to broadband, and many estimate that social determinations drive 80 percent of all health outcomes.
The pandemic has exposed a digital divide within our patient populations, and public-health experts studying the impact of broadband internet access on the nation’s health have called it a “super-determinant” of health because many of the others—such as education and employment—depend on broadband access.
On the other hand, telemedicine does solve some problems; for example, a patient does not have to worry about taking so much time off of work for an appointment because they no longer have to commute, nor do they have to worry about transportation to and from their appointment.
Dr. Bekelman: This is especially true for younger patients with breast cancer, many of whom have to take the hormone treatment leuprolide monthly—sometimes for 5 to 10 years. It’s a significant burden that often means taking time off from work, but now they can receive their injections in their own homes at their own convenience.
What other changes in care that were put in place will continue in a post-pandemic world? And with those changes in mind, how can we continue progress in reaching underserved communities and building greater health equity?
Dr. Bekelman: It’s time to reimagine the role of hospitals and clinics in cancer care. The measures we have been taking to expand cancer care at home during the pandemic will make our health care system stronger and make cancer care better. Clinicians deeply appreciate the quality of care provided, and they are delighted by their patients’ enthusiasm. The program is here to stay.
Dr. Guerra: There has largely been a positive response to telemedicine, especially for psychiatry patients.
I have written an op-ed for The Philadelphia Inquirer that calls on all Philadelphians to take a public stance and continue calling for increased broadband access for all. The time to act is now—before the digital divide becomes a chasm on the quality of nation’s health care, education and other opportunities that will reduce our overall human potential.
Dr. Bekelman: Achieving health equity in cancer care is a north star for us. We just received a large grant from the National Cancer Institute to focus on health disparities and financial toxicity, so that cancer care becomes more accessible and more affordable.
Many thanks to Drs. Bekelman and Guerra for sharing their insights on how cancer care has evolved in response to the pandemic. Stay updated on Penn Medicine’s COVID-19 policies and the Penn Center for Research on Coronavirus and Other Emerging Pathogens.