Introduction

[00:00:00] Stacey Richter: Spotlight Episode, "Oncology Side Effect Management in the Real World". Today, I am speaking with Dan Nardi from Reimagine Care.

[00:00:28] Stacey Richter: Right out of the gate here, I wanted to thank Reimagine Care for sponsoring this episode. It's kind of a breath of fresh air, honestly, to have someone reach out, not only with an interesting pitch for a show, but also with an offer to help out financially.

Pulling off a show like this one is not cheap, and my Aventria business partner, Dave Dierk, and I are happy to fund the vast majority of it. But yeah, breath of fresh air, and thanks much to the team over at Reimagine Care for their sponsorship. My one disclaimer is that I have not personally vetted the solution, but there is a white paper available, link in the show notes, where you will also find some insights from Reimagine Care's work with Memorial Hermann Health System.

To listen to the episode or read the show notes with mentioned links, visit the episode page.

Importance of Side Effect Management in Cancer Care

[00:01:07] Stacey Richter: So, today, Relentless Health Value listeners, we are going to hear about doing at home cancer care, otherwise known as integrative cancer care, otherwise known as side effect management. This is the same topic, by the way, that I ranted about being so important in episode 442. In that last episode 442, Andreas Mang from Blackstone was talking about how the most common reason for readmissions is nausea after chemotherapy.

I mean, think about that. Avoidable with a capital A, expensive for everybody, and horrible for an already very, very ill person, patient. For the extent of the problem, again, please go back and listen to episode 442. But today, we're talking about how do you think about operationalizing the, hey, let's actually make sure cancer patients are proactively managed after they leave the four walls of the clinic.

Interestingly, helping patients get their questions answered and not show up needing emergency care or abandoning their treatment also gets high marks with nurses and doctors, which makes sense. Who wants to show up in clinic every morning? Dealing with a patient portal full of messages and questions, and too many patients hooked up to IVs in the ER?

I don't think the feedback of clinician teams, in other words, is insignificant, because we need to protect our clinical teams so they have the bandwidth to protect their patients. Dan Nardi, my guest today, is CEO over at Reimagine Care. Earlier, he headed up operations at Carrum Health, which I'm sure provided some great perspective.

Oh, and one last point, at the present time, Reimagine Care's clients are mostly health systems who white label this service. 

My name is Stacey Richter, and for once, this podcast is sponsored by somebody else besides Aventria Health Group. 

Dan Nardi, welcome to Relentless Health Value. 

[00:02:56] Dan Nardi: Thank you for having me, Stacey. I'm excited to be here. 

[00:02:58] Stacey Richter: This show is a little bit, I would say, of a companion show to episode 442. Admittedly, I went off about the issue that I see with oncology care. Tolerability is actually a point to be made as we're contemplating delivering oncology care, really keeping track of what's going on with the patient and the side effects that these, they are toxic, right?

Like the dose is the poison is really a thing. So if we're thinking about that, though, what actually are the problems here? Like why does it really matter, if I just ask you to kind of crystallize that point, why does it really matter when we're thinking about oncology patients to be really paying attention to what is going on with them and managing side effects and keeping track of their experience in air quotes.

Challenges Faced by Cancer Patients

[00:03:51] Dan Nardi: Well, I think most people would agree that the US healthcare system is challenging enough to navigate for just the average person. But on top of that, patients that are going through cancer treatment, it's to a whole different level. You know, the amount of complexity that gets layered into their treatment.

For patients that are going through this, there's so many different challenges and hurdles that they're asked to clear. There's access to care. You know, the vast majority of oncologists are based in urban settings, so for any patients that are in more rural settings, even suburban, like you're having to travel long distances to get that specialist care.

And there's also the concept that cancer is not just one disease, it's so many all tied into one, and so there's not one care pathway, there's not one plan, there's not one treatment, there's so much variability. And treatments have gotten so much better, which is helping patients live longer, but they're with all these new meds that are being released and the oral combined with other treatment pathways, just the complexity just pounds on itself.

And so, we're asking patients going through their cancer to tackle a lot and to be their own care coordinators in some cases. This brings a whole level of emotional and psychological stress on top of them and their caregivers, their families, and it's just, it's a lot. So there's, I could go on for a long time, but this is at the highest level. That's how, that's how I think of it. 

[00:05:13] Stacey Richter: You mentioned four or five things there. If we're talking about access to care, you know, if someone is situated nearby a cancer center, that's very different than somebody who's literally hours away from one. There's just this inherent complexity as we're talking about here, and then the variability therein and just like the stress of having your life on the line, it cannot be underestimated.

But let me ask you this, if I'm just thinking about this at kind of this highest level, what really is the downside to letting patients navigate this themselves? Is it just, you know, annoying in the moment and I am minimizing this? intentionally here. I'm exaggerating for purposes of clarity. But is this like, oh, the patient, it sucked for them in the moment, but at the end of the day, it really doesn't matter?

Or are there outcome issues and or financial issues here that wind up compounding when patients don't navigate this well? 

[00:06:07] Dan Nardi: It's both. I mean, in the moment, think about this. If you're a patient and you've got questions two in the morning, you just had your most recent treatment yesterday and you're now uncontrollable pain, vomiting, whatever that might be. You want to be able to get answers in the moment, and if you can't, what are you going to do? You're going to go to the emergency department. 

Reimagine Care's Approach to Oncology

[00:06:25] Dan Nardi: And so, being able to support patients in the moment, 24/7/365, with oncology trained care teams, to be able to give them the answer, the comfort, support them in the home, that will then lead to not only like giving them a better experience in the moment, but better outcomes.

And I'll use an example here. So, you know, the, the components of Reimagine Care that we have, it's more proactive, we're checking in with patients, we're obviously there for any reactive moments like the one I just explained early in the morning, but proactively we're checking in with patients for quick little pains throughout the week, we're able to help them catch some of these symptoms before they become like an 8 or 9 out of 10, right, that would require an ER and ED visit.

So, if we can support them in those moments and catch these a little bit earlier, we avoid those, there's cost savings for the entire healthcare system, it's a better experience for the patient. Also, very likely that they're going to remain on their treatment, continue taking their medication, remain on the treatment that their oncologist has already prescribed to them, which will then lead to better outcomes for them throughout the rest of this treatment journey.

So there's, it's, to go back to your question, it's both, right? There's the immediate term, like support we can give them, but then there's a lot of downstream outcomes that we're able to drive by supporting patients in the home. 

[00:07:40] Stacey Richter: Yeah, and in that earlier episode 442, one of the things that what got brought up there is the most common cause of readmissions is nausea from chemotherapy and readmissions are bad.

They cost a lot. You have a patient who's now back in the hospital for something, as you said, that's totally avoidable. And now their treatment is interrupted because they're literally lying in a hospital bed getting an IV for rehydration. So, you know, it's just pretty logical, I guess. And now I'll give a personal example.

I had a friend of mine who's in the middle of chemotherapy right now, and she called me and said that she was allergic to her treatment. So here she is saying she's allergic to her treatment. I'm listening to what her allergies are. I'm like, you had a really bad side effect. But like, if she thinks she's allergic, now she is halting.

The best practice med for her condition, as opposed to getting a dose adjustment. So you definitely can see the patient outcome side of this, that patients have their questions answered and get the right answer, as opposed to Dr. Googling and her deciding she's allergic to her therapy. At the same time, you can see that total cost of care could potentially diminish.

With Reimagine Care, you've said that you, in air quotes, do the hard stuff related to cancer treatment. What is the hard stuff? Like what is hard about what we're talking about? 

[00:09:04] Dan Nardi: There are a lot of companies that are helping to improve the entire cancer treatment journey, right?  From early upstreams, navigation, second opinions, early diagnosis, genomics, genetics treatment, obviously kind of the middle part of this, and then, and survivorship, and downstream palliative care. I'm going to first say all of this is important. Being able to help support patients through that entire spectrum is very, very important.

When we say that Reimagine Care is doing the hard stuff, what we're saying is like we're squarely in that treatment phase. We partner with the oncologists, with the health systems, community practices, to be an extension of their care. For that 97, 98 percent of the journey that happens outside of the four walls, we help meet the patients where they're at.

Proactive Patient Support With Remy

[00:09:52] Stacey Richter: Yeah, there's this term integrative oncology, and we had Dr. Ethan Basch, who did a big study about integrative oncology on the pod, it was 2017, it was quite a while ago. But one of the things that he said loud and clear was, you can't really do integrative oncology well unless you're collecting patient reported outcomes and you're measuring things and you really have a way that you're touching base with patients when they are not in clinic.

So, say that I am a patient, I have just gone and gotten my infusion. It's now going to be two weeks, say, before the next one. What do you guys do? Because a lot of times patients will not reach out. 

[00:10:30] Dan Nardi: We check in a couple of times each week, just like, hey, how are you feeling? Are you having any of these symptoms?

And then we're able to walk through, so we have an AI-based virtual assistant, we named Remy. And so Remy is able to communicate proactively, checking in, seeing how you're feeling, and you can either respond and work through those pathways then, or just knowing that Remy is available 24/7. That example I had earlier of 2 in the morning, you may start interacting with Remy then.

And so whether it be calling the number directly or interacting through the virtual assistant, also, we mentioned earlier ePROS, so patient reported outcomes. We reached out once a week, we're able to kind of aggregate that data. Combined with the other symptom responses and the real-time patient data, we're able to aggregate all of that plus all of the historical data we know about you from the EMRs and the prescriptions and the treatment plans, other data sources.

We're able to have this really full and rich data set that allows us to surface this to our care team and eventually, if needed, surface it back to the oncologist to help make the best possible decision for you, the patient, in the moment. So it's like, we're filling those gaps proactively and reactively in between those two weeks, you know, spans between treatments.

[00:11:52] Stacey Richter: You're reaching out proactively. So patient goes home. And they're getting, is it a phone call, is there an app that gives notifications, like how does this, how does Remy talk to people? 

[00:12:04] Dan Nardi: We chose text as the lowest barrier to entry. Patients of all different ages and demographics, they're able to interact and connect and ask questions and then we're able to surface that and transition it to one of our care team members.

If those interactions and responses kind of bubble up, our team can take that over in real time. We can then transition it to a phone call. We can transition it to a video visit. We want to meet the patient where they're at in the moment. That's how we've chosen to tackle this. 

[00:12:33] Stacey Richter: AI is sending proactive texts, can answer some basic questions. If things start getting dicey, there's a person that starts stepping up. Because I'm assuming that how you're measured, your performance is measured. Is like how many patients don't go to the ER? How many patients continue with their treatment and don't step out? You know, I'm sure there's maybe other outcome measures.

Impact on Healthcare Providers and Systems

[00:12:56] Dan Nardi: Yes, avoidable ED visits is certainly one metric that we track and we just announced an expansion of Memorial Hermann. We're really excited about expanding across their entire population. One of the key metrics that we tracked during the initial phase of our implementation with them was those avoidable ED visits.

We actually, the goal was to be below 12 percent and we actually, through our program, we're actually able to see it be closer to four to five percent. So a huge decrease. Not only do we blow away the goal, but well below industry average. That is a big outcome. There's a white paper we put out last month.

We have side by side patient populations where we're just doing maybe phone triage for one group, but we're doing the full Remy integration and triage for another group, we are able to see a really great improvement of catching the symptoms of lower severity for the Remy engaged population. This technology plus services combination.

Which then just avoids those, those issues bubbling up and meeting whether it be ER/ED visits, whether it just meet like more intensive responses from our team or, you know, escalations back to the existing oncologist. We're excited to continue to track these and monitor these and bring in other outcomes as well.

[00:14:12] Stacey Richter: So we will definitely link to that white paper in the show notes. And I bet it's surprising for clinical teams. It's really difficult for the in clinic teams to even know how many of their patients wind up in the ER, I've heard. 

[00:14:26] Dan Nardi: Yes. I mean, we all know that the healthcare, we end up with all these silos, data silos, and all these other things.

And so, yeah, that happens a lot because especially if you're going, let's say a patient had to drive in a couple of hours to go to their oncologist, but now they're home, they're having an issue to go to their local emergency department. It might be in a totally different health system. So they may not know for weeks, months, or ever that that patient actually had that experience. 

[00:14:51] Stacey Richter: So you are hired by health systems, ie, the whole white labeling. 

[00:14:57] Dan Nardi: Correct. 

[00:14:57] Stacey Richter: How do doctors and nurses feel about Reimagine Care? 

[00:15:01] Dan Nardi: That's a great question. I think we have mixed, mixed feelings depending on the time frame when we initially started implementing having some of these conversations. The knee jerk reaction is to like, oh no, you're going to take over my patient relationship. You're here to disintermediate. And we very clearly work with them and say, no, we're not. We're here to help you be better and be in more places at once. From decisions like we're white labeling, we're charting right in their EMR, so it's a single source of truth for our patient record.

We are there to truly be that extension for them and allow them to see more patients, be more effective for their entire population. And so, you know, with the initial phase that we had at Memorial Hermann, we saw we had one oncologist that started with us for a period of time and we were measuring a whole bunch of different things and one of the key ones was actually, new patient volume.

So we were able to help support that provider in taking on 9 percent increase in their new patient volume over their peers during that time in their previous benchmark and years prior. And so it's not only being able to see more patients but quality of life. Our Net Promoter score on our provider side is amazing, you know, and we built this program more from a patient perspective, but to see the impact it's having for providers is truly outstanding for us. And so we have quotes like, you know, I've now been able to have dinner with my family a couple of times this week for the first time since I started here, or, you know, I've had the best sleep of my life since becoming an oncologist, like that's not hyperbole. That's a real impact that we're having for people providing care.

And so that really is what kind of keeps us coming back. Obviously, patients first. But the fact that we can have such an impact on such an important group in the healthcare system is truly life changing. 

[00:16:42] Stacey Richter: So it sounds like at the beginning, the, maybe the response is, you know, you come in and say, we would like to “reimagine care” and the response is, we got this, like, what are you saying that I'm not taking care of my patients?

It sounds like the conversation has gotten a lot more nuanced than that. It's not a matter of, is anybody doing a good job or not doing a good job. The nuance is, how do I want my nurse to spending their time? How do I want my APPs to spend time? Because if there's somebody that can take care of those phone calls at two o'clock in the morning so that I don't walk in every single day with seven emergencies, right?

Ensuring that we're purpose building for the needs of our patients so that everybody can do their job as best as possible and nobody gets stuck in kind of this reactive loop. It sounds like more people are recognizing the operational needs here. 

[00:17:35] Dan Nardi: Absolutely. And I think healthcare for a long time has also had the we can do it better than anyone else, right? You go to the health system and everyone's like, we can do it better. And they have an entrepreneurial spirit, which is awesome. But there is coming a time where we can't just keep doing the same. We can't just keep throwing bodies at it and solutions like ours, technology enabled services and bringing the right care teams at the right moments to support patients.

This is where we can help augment that and bring in this new version of cancer care. That's what we're excited for and we've been really great partners on the early stages of our journey and excited to be announcing a handful of more partnerships in the next couple of months that are, I think will continue to show the momentum that we're building.

Conclusion and Contact Information

[00:18:20] Stacey Richter: Dan Nardi from Reimagine Care, where can people go to get more information about the work that you do? 

[00:18:27] Dan Nardi: Yeah, we can go to the website, reimaginecare.com, exactly how it sounds. Like I said, our white paper is out there, we'll share a link to that. You know, we're excited to have any support along the way. So happy to connect with any organizations, any individuals that would like to help us in our journey. 

[00:18:44] Stacey Richter: Thank you so much for being on the podcast today, Dan Nardi. 

[00:18:47] Dan Nardi: Thank you for having me. Appreciate it. 

[00:18:49] Tom Nash: Hi, this is Tom Nash, one of the RHV team members. You might recognize my voice from the podcast intro.

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