Historically, it has been difficult for providers to shift cancer treatment into the home, despite high demand from patients for home-based chemotherapy and infusions. A host of barriers have prevented hospitals from implementing and scaling home-based models, including:
- Drug safety and stability: Cancer medications need to be stable and safe for home delivery, especially when compounded. Providers also must ensure the drugs can be stored properly, at the right temperature, prior to administration.
- Staffing and efficiency: Nurses who perform home infusions can often treat a maximum of two patients per day, compared to 10 to 12 per day at outpatient infusion centers. Home-based infusion also requires additional staff training and accreditation.
- Patient complexity: Many patients have vastly different care requirements, diagnoses, and comorbidities, which makes standardizing eligibility/exclusion criteria difficult.
- Finance and reimbursement: Payment models generally favor in-hospital care, which disincentivizes providers to shift volumes to the home.
- Equity: This is the factor that underpins all the others. What happens to patients experiencing homelessness or unstable living conditions? Or to patients living outside a hospitals' radius of care? Health systems with their own home oncology models, such as Penn Medicine and its Cancer Care at Home program, still see limitations around equitable access when patients live far away or don't have suitable homes for safe infusions.
However, we found in our recent global market trends series that, while Covid-19 has not removed or decreased these barriers, it has propelled some (more agile) organizations to capitalize on the heightened demand for home care.
In addition, we are seeing a global rise in third-party providers that are scaling-up equitable home cancer services to either compete with providers directly or become the partner-of-choice for hospitals to commission their cancer treatment volumes out to. Because of their low fixed-cost base, these third-party companies have a competitive advantage over incumbents—they can use their capital to invest wholly in creating a new service infrastructure that solves the barriers listed above, instead of using that money to shift from one infrastructure to a new one while operating both.
Hope for Tomorrow's 'ChemoBus' partners with hospitals to provide mobile cancer services
One of the more fascinating models we have seen increase equitable, 'at-home' access to chemotherapy infusions comes from the United Kingdom, where a 'ChemoBus' literally brings services to the community.
In 2007, United Kingdom-based charity Hope for Tomorrow created its Mobile Cancer Care Unit (MCCU). The unit—nicknamed a 'ChemoBus'—is a roaming cancer care, dispensary, support, and infusion service that is staffed by two nurses and can see up to four patients at a time at a preferred care location.
Hope for Tomorrow doesn't provide staffing, treatments, or services themselves. Instead, the organization operates a unique partnership model, which offers a middle ground between a provider fully operating a model themselves, and fully outsourcing it to a third party. Hope for Tomorrow provides and maintains its fleet of vehicles as well as any licensing requirements—all of which is paid for by fundraising. The organization then partners with local hospitals who provide staff, coordinate and operate care services, conduct risk assessments, and define eligibility and exclusion criteria for their patients. Hospitals have full agency to adapt the unit however they want and provide whatever services they want.
'ChemoBus' delivers equitable infusion to cancer patients
Importantly, the MCCU helps scale community-based chemotherapy as it opens up the services to many more patients who would otherwise be ineligible for home-based infusions. This includes patients from unstable or unsafe housing and disadvantaged neighbourhoods. When these patients are asked where they want to receive their care, many actually prefer for the unit to be stationed closer to their work, or their children's school, so this model provides a great deal of flexibility for patients who would otherwise struggle to make every visit.
Past equity, the 'ChemoBus' model overcomes many of the barriers that prevent hospitals from implementing and scaling home-based models:
- The small nurse-to-patient ratio means a high level of personal care and relationship building between patients and staff
- The ability to perform four infusions at once means the MCCU can perform an average of 20 infusions per day
- MCCUs typically contain medication storage and cooling facilities
- Telehealth links with the hospital enable rapid escalation of care in rare occurrences of adverse reactions to medication
Hope for Tomorrow now partners with 13 hospitals around the United Kingdom, operating 11 individual MCCUs, and the program has administered over 85,000 treatments on board its units. And by referring patients to these services, hospitals are not only able to provide care for more people, but they can also ensure inpatient and outpatient capacity can be reserved for higher complexity patients.
This was particularly vital during the pandemic where, despite capacity and staffing constraints, the service increased usage and saw a 39% increase in patient visits in 2020 compared with 2019. One partnering hospital has even shifted 62% of its traditional cancer treatment into a mobile unit during the pandemic, freeing up space for more complex patients to be seen in-person.
Hope for Tomorrow's MCCU model is unique and, with demand for its services increasing, we may yet see more NHS hospitals partnering with the charity over the coming years. Especially because it is clear that patients love it."I am so glad that I found out about Hope for Tomorrow; it really has transformed my life. There are so many benefits – the convenience, easy parking, and a lovely team. The staff are so personable and courteous, and the units are delightful" - Chemotherapy patient, Norfolk, U.K.