Setting: Large academic hospital with ambulatory oncology program

Target Audience: pharmacy manager who is not an oncology pharmacist

Oncology service level required: Enhanced

Experience: clinical high, oncology low

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Emily is a clinical pharmacy manager at a large academic hospital and oversees the facility’s ambulatory oncology pharmacy program.  They recently had a long-time oncology pharmacist retire from their medical oncology pharmacy team supporting patients with breast cancer.  Emily was able to recruit Amir from the hospital’s general pharmacy team.  Amir has completed a Year-1 Canadian hospital pharmacy residency which included an ambulatory oncology rotation 10 years ago.  He has since been working in the main pharmacy and on an inpatient general surgery unit.  He has minimal exposure to oncology-specific medications, protocols and patient management.

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1. How should Emily approach Amir’s initial training?

Before jumping into the planning for Amir’s on-boarding to the oncology pharmacist role, Emily should take a step back and fully contemplate the need she must fill. 

• What must be done by the pharmacist in this role? - understand the role as it is desired, not necessarily as it was
• Emily  must also understand what Amir’s current gaps in knowledge and skills are in relation to what the needs are in the role. To do this, he could ask Amir to complete a self-assessment.

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2. What are  the patients' needs from their oncology pharmacist?

• The  ambulatory clinic offers both essential and enhanced clinical services.
  
  • Both services are well established 
• Emily has teams of clinicians providing support to patients receiving anticancer medications for breast cancer, lung cancer, GI cancers and hematological malignancies.
• Her clinicians provide this support through a pharmacist-led toxicity management service
  
  • As part of their service, referred patients under their care receive:
    
    • A booking for initial assessment and education
    • Baseline toxicity assessment
    • Initial education about importance of treatment, adherence, expected toxicities and their management
    • Follow up adherence monitoring at each pharmacist-patient interaction
    • Follow up toxicity assessment post first cycle (timing is treatment-dependent)
      
      • Resolution of any DTPs
    • Pre-cycle assessment within 48 hours of subsequent cycle for first 3 cycles
    • Follow up toxicity assessment post subsequent cycles for first 3 cycles
• The pharmacist leaving Emily’s team was providing enhanced services to breast cancer patients
• While Amir will need to provide  enhanced services, initial focus should be on essential services as a foundation for his knowledge because oncology is new to him overall.
• Once Amir is confident  and competent in providing essential services, he can begin training for enhanced services

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3. What level of service will be provided - essential or enhanced?

• For this case, the assumption is that Amir has developed the knowledge, skills and abilities to provide essential services
  
  • His training program was individualized through the process identified in Case 1
• The remainder of the case will focus on the needs for competencies associated with enhanced services:
  
  • Monitoring and management of cancer and anticancer medication associated toxicities or adverse drug reactions
  • Monitoring and management of anticancer medication adherence
  • Provide clinical follow up for patients receiving anticancer medications after their first encounter
  • Development of a pharmaceutical care plan related to a patient’s cancer or cancer associated medications

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4. What competencies should Emily consider for Amir’s training plan?

• Competencies associated with Enhanced services:
  
  • All of the essential competencies described in case 1 plus:
  • Pillar 2 - Knowledge of Cancer and its Management
    
    • Amir will need to be maintain knowledge and skills to provide enhanced oncology services such as:
      
      • Supportive care and toxicity management
  • Pillar 3 - Safe and Appropriate Use of Anticancer and Supportive Care Pharmacotherapy
    
    • As part of his service, Amir will be required to discuss strategies to optimize patient adherence to cancer-related pharmacotherapy 
    • He will be required to assess and follow up with patients prior to subsequent cycles of treatment
  • Pillar 4 - Person-Centred Care in Clinical Oncology 
    
    • Amir will need to be able to communicate effectively with patients to gather the required information and make decisions about their treatment with their individual needs/goals in mind including:
      
      • Establish and maintain a professional relationship with the person with cancer and their care partner(s)
      • Gather relevant information in the provision of patient care
      • Assess the patient’s cancer-related pharmacotherapy needs
      • Identify actual and potential drug therapy problems (DTPs) affecting cancer-related pharmacotherapy
      • Develop a patient-centered care plan addressing cancer-related pharmacotherapy needs
      • Implement and follow-through with the care plan
      • Educate, engage, and support patients and care partner(s) regarding cancer management
      • Prioritize health equity, inclusion, and accessibility in patient care activities

5. What other issues should Emily and Amir consider in consultation with their senior pharmacy leaders, physicians/prescribers and allied healthcare practitioners?

• Which patients to target
  
  • Emily’s team has an established service, however she should consider this an opportunity to review their priorities and consider realignment if needed
  • Refer to the evidence section of the toolkit …
• What needs/gaps are identified by the healthcare team from their current patient care services?
  
  • Emily should work with her collaborators in the clinic to determine if there are any gaps identified
• What is the timeline?  When do they need Amir trained and ready to step in?
  
  • Dependent on the needs of the clinic 
    
    • Can any other pharmacists on the team support until Amir is trained
    • Targeted orientation if needed (e.g. order review initially to get foundation and then shift to focused breast cancer training)
  • Dependent on competency and knowledge uptake
    
    • Timeline may be extended if needed

6. What resources are needed? What resources are available?

• Refer to resources document to select resources whose learning objectives align best with the learning objectives for Amir’s training

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7.  What approaches can be added to develop skills and attitudes? In addition to the required knowledge to fulfill the role providing enhanced services, what opportunities can Emily arrange for Amir to facilitate preparedness for this level of oncology practice?

• Identifying a clinician as a mentor for the first 3-6 months
• Given the heavily integrated role Emily’s team has established, Amir should spend extended time with the breast cancer team (oncologist, nurse, schedulers, etc) to better understand their workflow and needs
• Structured shadowing (with objectives) developed including:
  
  • RPh
    
    • Reviewing essential and enhanced service roles for pharmacists 
  • Prescriber/oncologist/hematologist
    
    • Patient assessment, treatment decision making
    • Needs for pharmacist
  • Oncology technician mixing/checker
    
    • Drug storage
    • Preparation
    • Final product checking
  • Drug Access Navigator
    
    • Funding process
    • Needs for pharmacist
  • Nursing
    
    • Drug administration process
    • Patient support process
    • Needs for pharmacist

10. What is the implementation plan?

• Schedule for training
  
  • Individualized to Amir’s self-assessed needs
• Assessment plan 
  
  • Emily should schedule regular check-ins with Amir
  • Emily should schedule separate, regular check-ins with Amir’s mentor
  • Emily should plan to follow up with other members of the pharmacy team and the other Healthcare Professionals in the clinic
• Role of everyone involved
  
  • Clear expectations for Amir, his mentor, and other members of the pharmacy team
  • Clear communication with other Healthcare Professionals in the clinic

11. Evaluation

• Plan to determine whether goals and objectives are achieved
• Feedback from everyone involved about the process

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