Virtual Anemia Clinic

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepherd, a medical oncologist here at Cleveland Clinic Directing the Taussig Early Cancer Therapeutics Program and Co-Directing the Cleveland Clinic Sarcoma program. Today I'm very happy to be joined by Mailey Wilks, APP Manager at the Taussig Cancer Center, and Heather Koniarczyk, Director of Advanced Practice. They're here today to talk to us about a virtual anemia clinic. So welcome, Mailey. Welcome, Heather.

Heather Koniarczyk, CNP: Thanks for inviting us.

Mailey Wilks, CNP: Thank you. Thank you for having us.

Dale Shepard, MD, PhD: So I gave your titles, but give us a little bit of an idea what you do here. Mailey, we'll start with you.

Mailey Wilks, CNP: Yeah. So I'm an outpatient APP and hematology oncology at Main Campus at Cleveland Clinic. And in addition to that, I'm the APP manager of our outpatient team, and I help to see patients in hematology and oncology as well as develop our APPs in a leadership role.

Dale Shepard, MD, PhD: Excellent. And Heather, you're a APP manager for the Cleveland Clinic, so what does that mean?

Heather Koniarczyk, CNP:

Yeah. So the role that I play really talks about driving clinical practice and kind of the business operations of APPs, focusing on quality of the work that APPs are producing, working on benchmarks as this is a newer specialty or especially in oncology, the role keeps changing and advancing. As a director, I get to focus my energy not only here at our main campus, but I get to work with all of our FHCs, all of our Ohio hospitals as well as our Florida and London colleagues as those programs develop. So it's a great experience.

Dale Shepard, MD, PhD: So Heather, let's start with you. We're going to talk about this virtual anemia consult clinic. I guess we had a problem with hematology and anemia. Is that safe to say?

Heather Koniarczyk, CNP: Yeah, I would definitely agree with that. We've always had plentiful anemia consult requests from the organization inside and outside of our organization. But in 2022, we kind of had a few things happen that really expedited our need for a change. So we had some physician resignations in our classic hematology group and there's a national shortage of those physicians.

So replacing those physicians has been a really long process. So we were down physicians. And then we also saw a very large increase in the requests, double what we generally see for anemia consults. So it kind of was the perfect storm and it made us really go into hyper speed of trying to find a solution.

Dale Shepard, MD, PhD: When we think about the huge increase in consults, what do we think caused that?

Heather Koniarczyk, CNP: I think it's a couple things. So I think COVID, a lot of patients probably didn't seek care and we had a lot more people kind of trickling into their primary care physicians or their, getting ready for their surgical procedures that were put off. And then they had some pre-admission testing done.

We still have a large group of iron induced pregnancy patients, so those patients were pretty steady throughout and we continue to take care of them. But really just mostly medicine patients that are coming to see us. And then I would say that oncology and hematology are starting to become very specialized, that I feel like it's a little bit easier to get a second opinion and people want that second opinion in the community. So I think they seek us out sometimes for that.

Dale Shepard, MD, PhD: So it's kind of a combination of surgeons and primary care and patients themselves.

Heather Koniarczyk, CNP: Absolutely. And we have so many chronic disease patients that even rheumatology or some of our other consulting colleagues will get us looped in on anemia.

Dale Shepard, MD, PhD: All right, excellent. So Mailey, you talked about some work we've done at the recent ASH meeting. Maybe tell us a little bit about the background on that.

Mailey Wilks, CNP: Yeah, so as Heather mentioned, in 2002, we really needed a solution to this problem. And the day's wait for our patients was certainly beyond our goal of seven days. We always try to get patients in for a new consult within seven days in our institute for many reasons because patients need to be seen, it could be urgent, but also alleviating the fears that that patient has when they get that referral to hematology, oncology.

And so we were actually over 20 days in hematology at that point. That was the average wait. So what we did was develop a virtual anemia consult clinic that was led by our advanced practice providers. So we still saw patients in person, but we thought that the virtual platform would allow us to extend our opportunities to see many patients in one day at convenience for patients and really help to decrease that number of days wait.

There were a lot of variabilities and reasons for why it was taking that long for a patient to get in for a consult, but one of those two was just the scheduling of trying to centralize a schedule for them and just having the provider availability. So we were able to have a centralized schedule that all of our APPs could help to staff, and that allowed patients to be centralized and scheduled directly into that clinic.

So we started with five consults per day. So we'd have an APP staff at every single day, a different APP. And then patients from everywhere in the state of Ohio were able to be scheduled into that. So not only were we able to schedule our patients who lived locally in the Cleveland area, but also in other counties in Ohio. So patients didn't have to drive three hours for their visit to start, which was really great.

So from that we were able to see from September of 2022 to May of 2023, a total of 610 in state consults and we're well beyond that now, over probably a thousand in current time. And we were able to bring that wait time from 20 days to eight days wait for our anemia patients and for access to hematology with the virtual anemia consult clinic itself at a median wait of four days.

And also it really helped to improve our APP revenue and productivity as well increase the slot utilization for them. And patients just verbally in our conversations with them, just very thankful for the opportunity to be able to be seen quickly. So all of that was published in an abstract for American Society of Hematology.

Dale Shepard, MD, PhD: Excellent. So Heather, when we think about more global, what did it take to actually set up a clinic? I mean, what was kind of involved in logistically saying, "We're going to do this?"

Heather Koniarczyk, CNP: So like all good projects, a multidisciplinary team was created and it was created very quickly. We kind of went from start to finish in only six weeks. And so I'll talk a little bit about what we did in those six weeks. So our first step was working with the hematology staff, the APP team, APP leadership, and then our scheduling team to kind of look at the holes and look at opportunities and why we're having this backlog.

And we found that it was related to three different things, one of them being lower APP utilization. We noticed that we had 30% of our consults vacant, so there was some room to use those. The second thing was scheduling turnover from the personnel. So they had a hard time every time they had a vacant position and refill to train, to look at all these different APP schedules to know what disease or what diagnosis for the consult would be appropriate for the APP.

So that partnered with the APP slot utilization and in the scheduling issues really created some light bulbs for our multidisciplinary team. The other thing is that generally for straightforward consults, and I hope my colleagues don't get mad that I say this, but generally it does not take 60 minutes to see a straightforward anemia consult. There are definitely a lot of complex anemia consults that our APPs and our physician see that do.

But if you average that, they take between 30 and 45 minutes or so to complete. So that was also an opportunity to be able to see more patients by decreasing the length of that slot and creating more. So with those, we kind of put our money where our mouth was and went into action. And initially we were thinking of not a virtual platform. We thought we needed to hire all these APPs and put them in the region.

And we found so many limitations with that. We didn't have space for them at any of the FHCs or the cancer centers that are throughout Ohio. And then it didn't alleviate any of the scheduling issues with the schedulers not kind of being abreast of how to do all those specific consult diagnoses. So in talking with Dr. McCrae, we kind of talked about limiting the ICD-10 codes and having them be virtual because I think our virtual platform has really evolved over the last three years. I'm sure most would agree with that.

So it's really been a tool to kind of look at care differently. And I think it's really helped to kind of change the way we think. And it was kind of an experiment for our institute because we hadn't really had a full virtual clinic before. So we set it up with five consult slots, 40 minutes long. We rotated our APPs through there. They kind of covered the clinic one day a week and then went back to their own personal schedules and templates the rest of the week. And we filled up right away, 90% full in the first week.

Dale Shepard, MD, PhD: That's fantastic. So Mailey, talk to us a little bit about what does that consult kind of look like? You've seen people from a wide range of areas, so some of our own patients, some of them are people more remotely. Do you usually have what you need from a test standpoint? You talk to patients with what you have, how does that go? How do you arrange follow-up? What if they need iron or how do you collaborate back with people who might've referred?

Mailey Wilks, CNP: Yeah, all great questions. We certainly are navigating that piece of it as we continue on with the clinic, but I think that virtual visit provides the opportunity for us to do a very thorough history. Sometimes we have all of the records that we need because they're an internal Cleveland Clinic patient already. Other times they're outside of the Cleveland Clinic system, so we're relying on Care Everywhere or scanned records.

So that can be challenging. Sometimes the labs are a day or two old and other times they're a couple months old. But I think that virtual platform allows us to do that triage with the patient and obtain that history, see what labs are needed. So when it is a very straightforward, or I should say maybe a nutritional anemia where they need IV iron, we can set up their IV iron infusions and start that process.

And maybe they see us, but they go to a regional location to receive their IV iron infusions. And that provides patients a lot of flexibility in being able to do that. And other times we may not have all the information that we need, so we can either bring them in for an in-person visit to continue that evaluation, obtain more labs. But we try to order the labs that we can with the information that we have.

Sometimes the cases are very complex and we need to involve our staff physicians right away and we do. And then other times we're able to see them in person. Sometimes it's just a one-time visit, maybe it's just they need that reassurance. We've also had patients that we've diagnosed with leukemia, acute leukemia and myeloma and MDS.

And so I think there's value to having this clinic because maybe they would've had to wait 25 days for a visit if they had been referred for anemia and it wasn't recognized that they actually had acute leukemia or myeloma. So we're able to really start that workup and evaluation for them. We're sitting at about a little bit over a 70% retention rate with these patients. So of the patients we're seeing, over 70% are staying with us and our APPs and our staff physicians for follow-up visits and additional treatment and evaluations.

Dale Shepard, MD, PhD: And then do some of those patients continue seeing APPs sort of in a virtual setting for follow-ups, or do they usually start being seen in clinic?

Mailey Wilks, CNP: So that can change as well, but we try to see them at least once in person. That's kind of required for most insurance companies. But we do offer that virtual follow-up, which I think is very convenient for the patients. They appreciate that. And then sometimes maybe they live in Sandusky or they live in Erie PA, so it would make more sense for them to get established with an APP or provider locally and see them in person. So we've also done that as well. But the goal is to see them evaluate and start treatment if needed as soon as possible, and then we can get them established with somebody for long-term care.

Dale Shepard, MD, PhD: Yeah. I guess, Heather, we've been talking about taking care of patients in Ohio, and of course we have locations, many, many places. We have patients that come in from other places. Part of this, of course, most is really driven by insurance and the requirement that patients be here in Ohio. Right?

Heather Koniarczyk, CNP: Mm-hmm.

Dale Shepard, MD, PhD: Is there a thought to maybe expand this sort of service into Florida, for instance, or?

Heather Koniarczyk, CNP: Florida's very interested in this model and I've met with them quite a few times to talk about the logistics. I think locally they have the APPs that are interested. I think the thing that would be different from main campus to Florida would be the classical hematology expertise, as in our APPs here are only seeing classical hematology versus in Florida they're very general in practice with hematology and oncology.

So that would be kind of a concession or a change that would probably be in the best interest of the group if they... I mean, they do. They have a large number of consult requests as well. And the thing that happens when you're overloaded with anemia consults is it starts to push out the oncology longer, which nobody wants. We want those patients to get seen as soon as possible.

Dale Shepard, MD, PhD: Within cancer diagnosis, there's certainly like our virtual second opinion service that people in any state can utilize because it's kind of more of an educational service rather than treatment or diagnosis. Is there a thought that this could be beneficial in that setting as well?

Heather Koniarczyk, CNP: I'd really have to look more into what the logistics from the APP scope would be around that and probably kind of brainstorm with our executive leadership on that. I think it's a really interesting idea. I think it'd be very hard for the APPs being the caring natured people that they are to not try to dig into labs and get a little more specific. And I just myself, I know I would want to, but it's something we could definitely consider moving forward.

Dale Shepard, MD, PhD: Yeah. You mentioned Dr. McCrae, who's one of our classic hematology. Mailey, tell us a little bit about that sort of physician interaction. You do huddles, is that right?

Mailey Wilks, CNP: Sure, yeah. We have a lot of support from our staff physicians and they've trained us to be classical hematology APPs. Dr. McCrae's been very supportive and also Dr. Dana Angelini. So if you think of it kind of like a oncology tumor board, we meet weekly and we huddle all of the APPs who staff this clinic with a staff physician. And we present cases, complex cases that maybe we want to run labs by or results by.

And it's a great learning opportunity. And then in addition to that, our staff physicians provide additional education.. So maybe there's a specific case and then they'll provide a little bit more extension of education or laboratory evaluation or interpretation. So it's a great learning opportunity in addition to just getting to know the practice of patients that we're seeing and a lot of the complex cases that come through.

Dale Shepard, MD, PhD: So I guess a question kind of to both of you, maybe a little different perspectives, what do you find has worked best and what might be the point where we make big improvements? What's the next step forward?

Mailey Wilks, CNP: Well, I think one of the challenges we've run into is care coordination because we're seeing such a high volume of consults and we want to make sure that those patients get that continued care coordination throughout their time and just making sure that they get their follow-up appointments.

And so I think there's an administrative nursing care coordination support that we would love to incorporate into this as our volume continues to increase. I think we're planning to add additional consults with more staff and increase our FTEs for APPs. And I can let Heather speak to that a little bit more, but I think we just need to build the infrastructure a little bit more so that we're able to support the high volume that continues to come in.

Dale Shepard, MD, PhD: Yeah. Heather, what? And I guess related to that, are there other diagnoses as we think about expansion?

Heather Koniarczyk, CNP: Well, in regards to other diagnoses, we are kind of throwing around the potential for evaluating a little bit of thrombocytopenia potentially. But that comes with some challenges with the patient being virtual. Having a blood smear is kind of the holdup there, that we wouldn't have one at the time of seeing the patient. So we are still trying to brainstorm. Our VTE clinic is run by our APPs as well, and it was initially run by our hematology APPs and then kind of migrated into our urgent care that we created a few years ago.

But that's another potential follow-up with the patients to see how they're doing virtually. Or there's just such a high number of those patients so we could potentially think of making some branches off of that. But our APPs really do have such a strong commitment to our patients and supporting them with the right number of FTEs is really important to us. So I just learned today that we have three additional FTEs that were approved, so we'll be able to expand into more consult slots to help our patients and support our APPs with having a reasonable number of consults. I don't know if Mailey mentioned this earlier, but it is seven consults per day. That's...

Mailey Wilks, CNP: We've increased it.

Dale Shepard, MD, PhD: It's impressive.

Heather Koniarczyk, CNP: Yeah.

Mailey Wilks, CNP: We've increased.

Heather Koniarczyk, CNP: I don't really know too many practices that do seven consults in one day.

Dale Shepard, MD, PhD: Yeah.

Heather Koniarczyk, CNP: So I think it'll be really important to have those three additional classically hematology trained APPs. That'll also be able to maybe have some in-person clinics in the regional spaces, which I think the regional teams would really find beneficial.

Dale Shepard, MD, PhD: And then I guess you've done a lot of consults, and so you have a lot of experience. You see a lot of things coming through the door thinking about sending people for an anemia consult. Very practical question. Mailey, I'll shoot this one to you. What would you like people to have had done before they saw you? Are there people that clearly need to see you and are there people you're like, "I don't know. Did they really need to see me?" I mean, give people a little bit of advice on how to use an anemia clinic.

Mailey Wilks, CNP: Yeah, that's a great question. I think the things that are helpful, we work very closely with our primary care providers and they're wonderful and they see a high volume of patients. So the first thing when you ask that, that sticks out to me is nutritional anemia, because that tends to be the most common and iron deficiency anemia being the most common female patients, whether it's childbearing ages, and pregnancy or from menstrual cycles, we lose iron.

And so trying to treat that orally first with an oral iron supplementation can be done in a primary care setting. And so I think starting there. And if we find that there's reasons for lack of absorption or they're just not able to correct their anemia that way, then that's where I think that second opinion or just getting a further evaluation for possible IV iron or working up the anemia further.

Because as we all know, anemia can be caused by many different things. They can have iron deficiency anemia, but also have hemolysis at the same time, so there's a further evaluation that needs to be done. But I think having the most recent labs, lab work within the last couple of weeks would be great to start and just having those records available so that we can have a really meaningful first consult with them.

Dale Shepard, MD, PhD: Makes sense.

Mailey Wilks, CNP: Yeah.

Dale Shepard, MD, PhD: Heather, Mailey, you guys are doing great work.

Heather Koniarczyk, CNP: Thank you.

Dale Shepard, MD, PhD: Appreciate your insights.

Mailey Wilks, CNP: Yeah. Thank you for having us.

Dale Shepard, MD, PhD: To make a direct online referral to aour Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You'll receive a confirmation once the appointment is scheduled.

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