Last year, due to the COVID-19 pandemic, the home evolved from being a sanctuary for rest to being a nerve centre for daily activities - work, schooling, shopping and more. Even patient care was transformed.
As part of the national effort to socially distance and prevent disease transmission, the number of people who could attend healthcare institutions was restricted. Ways of minimising patients’ physical attendance at healthcare institutions, while seamlessly continuing patient care, were sought.
At the National Cancer Centre Singapore (NCCS) two patient-centric initiatives were rolled out to navigate the new normal: Home Care and Telemedicine. But, would these new models of care be comparable to the care received at the physical Centre? We take a look at how healthcare providers and patients evaluate them.
Administering cancer treatment at home
Launched in July 2020, the NCCS Home Care Programme administers treatment to patients in the comfort of their home. The Programme offers convenience and increased accessibility to care for the patient, particularly for those who are less mobile, and who rely on caregivers to arrange transport to and from appointments. In the time of COVID-19, it also achieves the goal of reducing the number of people at the Centre.
Treatment that may be given as subcutaneous (under the skin) or intramuscular (into the muscle) injections are suitable for administration at home while intravenous infusions are not. Patients for whom these injections are prescribed are eligible for the NCCS Home Care Programme.
The Home Care Programme was first piloted in breast cancer patients with the subcutaneous treatment Trastuzumab (brand name Herceptin). It was so well-received that other drugs were soon added to the list of suitable treatments. Examples include hormonal therapy (Goserelin, Leuprorelin, Degarelix, Fulvestrant) for breast cancer and prostate cancer patients, immune boosters (granulocyte colony stimulating factor, GCSF) and bone-modifying agents (Denosumab). To date, over 100 patients have enrolled onto the Programme.
NCCS has partnered with a team of trained nurses from Jaga-Me, a mobile health company, to administer the treatment. The drugs may be picked up from NCCS by the nurses on the day of administration, or delivered to the patients’ homes in advance. During the home visit, the nurse first assesses the patient’s vitals (temperature, blood pressure, heart rate) before administering the treatment, and monitors the patient for at least 15 minutes before leaving their home.
“We received positive feedback from patients on the Home Care Programme,” said Dr Elaine Lim, Senior Consultant, Division of Medical Oncology, NCCS, who initiated and is currently leading the NCCS Home Care Programme. “Around 98% of the patients surveyed said they were either satisfied or very satisfied with the service. The success of the programme is in no small part thanks to the tireless efforts of the NCCS Pharmacy team.”
In the survey, the top two reasons cited by patients for choosing the NCCS Home Care Programme were convenience (51%) and time savings (33%). One patient who has benefited is 76-year old Madam Quek, who was diagnosed with early stage breast cancer in August 2020. She completed chemotherapy treatment in December 2020 and enrolled onto the NCCS Home Care Programme the same month, to continue Herceptin. So far, she has had four Herceptin injections in the comfort of her home.
“When I finished my chemotherapy in December, my doctor told me, ‘Finished chemotherapy! We can send somebody straight to your house to continue the Herceptin injections.” Madam Quek explained, “At home, I’m relaxed, my husband is around and I don’t have to travel anywhere. It only takes 30 to 45 minutes for the entire session and the same nurse from Jaga-Me comes every time. I’m very happy with her and I think the Programme is a fantastic idea!”
Madam Quek was suited for the programme because her treatment could be given via subcutaneous injection. It was also a challenge for her and her family to coordinate visits to NCCS, because of COVID-19 safe distancing measures. The Home Care Programme has fulfilled its goals of helping patients continue to receive the treatment they need in a timely manner, with the added bonus of offering convenience and time efficiency for patients and their caregivers.
Consultation with patients via computer and phone
Cancer patients with palliative care needs often require support for various physical and psychosocial concerns. The Telemedicine Clinic in NCCS’ Division of Supportive and Palliative Care, is a 12-week programme that provides comprehensive palliative care via video and phone consults to such patients. This service is run by Advanced Practice Nurse (APN) Zhu Xia in consultation with Dr Shirlyn Neo, a consultant in the Division.
The Clinic caters to advanced stage 3 and 4 cancer patients. In the first week of enrolment, patients have a video consultation with APN Zhu and Dr Neo via Zoom. After that, they respond to a weekly questionnaire, Integrated Palliative Care Outcome Scale (IPOS) that is sent via SMS. This allows patients to report any physical and psychosocial symptoms they may experience each week.
Advanced Nurse Practitioner Zhu Xia and Dr Shirlyn Neo, Division of Supportive and Palliative Care, National Cancer Centre Singapore conducts the video consultation for the Telemedicine Clinic.
With the patients’ self-reported answers, APN Zhu follows up with a phone call to the patient to determine the urgency needed in terms of the clinical management plan. Another unique feature of the Telemedicine Clinic is that the weekly follow-up allows for timely adjustments to the treatment plan, when needed. APN Zhu discusses patients’ clinical plans with a palliative care consultant to ensure the patient gets the treatment they need.
“When we do the first consultation, it’s not just with the patients, but with their families or caregivers at home too. This allows us to build trust and rapport with the patient’s support system, which is important in their care journey,” said APN Zhu.
The Telemedicine Clinic has been an effective way for the healthcare team to support patients who require palliative care.
Cancer care of the future
The convenience, flexibility and patient-centeredness of the Home Care Programme, Telemedicine Clinic and other teleconsultation services have resulted in higher patient satisfaction scores at NCCS. Measured by the percentage of patients who would recommend NCCS a friend or family member, average patient satisfaction scores rose 3%, to 90.8%, during the circuit breaker period.
Teleconsultation follow-ups reduced total clinic consultations by 30.7% during the circuit breaker. With fewer physical consultations, safe distancing measures within the Centre were strengthened and the average median wait time was reduced by about 10%.
These scores and statistics evaluating the new programmes were reported by NCCS clinicians in the Annals Academy Medicine of Singapore and the Journal of Clinical Oncology: Oncology Practice. Encouraged by the findings, a committee has been formed at NCCS to consolidate the positive changes, create new patient-centric policies that will keep patients safe in this COVID-19 era and further improve patient experience.
To find out more about your eligibility for the Home Care Programme and the Telemedicine Clinic, patients can speak with their primary oncologist.
i Kanesvaran, Ravindran, Claramae S Chia, Swee Peng Yap, Michael LC Wang, Chee Kian Tham, Soon Thye Lim, William YK Hwang, and Jin Wei Kwek. “Cancer versus Covid-19: A Coordinated Disease OUTBREAK Response System (DORS) to Combat Covid-19 at the National Cancer Centre Singapore.” Annals of the Academy of Medicine, Singapore 49, no. 10 (2020): 807–9. https://doi.org/10.47102/annals-acadmedsg.2020291.
ii Kwek, Jin Wei, Jack J. Chan, Ravindran Kanesvaran, Michael L. Wang, Patricia S. Neo, Claramae S. Chia, Chee Kian Tham, et al. “Early Outcomes of a National Cancer Center's Strategy Against COVID-19 Executed Through a Disease Outbreak Response Taskforce.” JCO Oncology Practice, 2021. https://doi.org/10.1200/op.20.00535.
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