ICLIO Visiting Experts Application
Email address
Thank you for your interest in ICLIO Visiting Experts, a one-day, personalized learning initiative conducted by the Institute for Clinical Immuno-Oncology (ICLIO), an Institute of the Association of Community Cancer Centers (ACCC).

Held onsite January 2017 at your institution, the program will be conducted by the ICLIO Visiting Experts team. This four-member faculty team will provide a tailored curriculum on the nuances and complexities of immuno-oncology.

In order to be considered for this opportunity, your institution must meet all of the following criteria:

• Be a current ACCC Cancer Program Member in good standing

• Have already established—or are in the early stages of implementing—an immuno-oncology program, and be willing to discuss your practices with ACCC and ICLIO

• Identify and assign a champion to interact and coordinate with the ICLIO project team.

• Have treated at least 50 or more patients with immunotherapy in the last 12 months

• Have plans to expand your immuno-oncology program over the next 2 years

• Enlist commitment of 5 or more key oncology professionals who will participate in the program:
o Physician(s) (oncology, radiation oncology, surgical, internal etc.)
o Nurse(s)
o Pharmacist(s)
o Social worker(s)
o Financial counselor(s)
o Administrator(s)
o Other (e.g. nurse navigator)

• Approval for ACCC and ICLIO to publish key findings and outcomes from your workshop on their respective websites, as well as in white papers, social media posts, webinars, blogs, newsletters, and live education conferences.

To be considered for this opportunity, please submit this application to Brissan Guardado via email at BGuardado@accc-cancer.org

ACCC Cancer Program Name:
Your answer
Name of Individuals Involved in Completing the Application:
Your answer
What is Your Role on the Multidisciplinary Cancer Care Team?
Information about Your Immuno-Oncology Program:
1. On average, how many patients does your program treat with immuno-oncologic agents per year (Checkpoint inhibitors [anti-pd1s, anti CTLA-4s]/vaccines/other immunotherapies used to treat patients with cancer)?
2. Of the immunotherapy drugs prescribed at your program, how many cases per year are prescribed for each of the following tumor types?
0 - 25
25 - 50
50 - 75
75 - 100
>100
Lung
Metastatic Melanoma
Renal Cell Carcinoma
Bladder
Other(specify)
3. On a scale of 1 to 5 (with 1 being not operational and 5 being fully operational) please rate where the immuno-oncology program at your institution.
4. Please rate your staff’s knowledge of the following clinical characteristics of immuno-oncology (I-O).
No knowledge
Little knowledge
Don’t know/Not sure
Somewhat knowledgeable
Very knowledgeable
I-O Indications (specific tumor types treated)
I-O Mechanisms of Action
Response Assessment to I-O Therapy
I-O Sequencing Considerations (1st line, 2nd line, 3rd line)
Use of I-O Monotherapy vs. Combination Therapy
Management of immune-related Adverse Events (irAEs)
Use of I-O Biomarkers
5. Please rate the quality of the interactions and communications within your immuno-oncology multidisciplinary team (oncologist, pharmacist, nurse, administrator, other healthcare provider).
6. Please indicate your level of agreement with the following statements:
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
Our program experiences coverage and reimbursement barriers to immuno-oncology agents
Our program is able to handle pre-certifications or prior-authorizations for I-O use
Our program takes advantage of patient assistance programs and foundations for patient financial support
Our program has updated protocols and management pathways to account for patients treated with immuno-oncologic agents and immune-related Adverse Events (irAE)
Our program provides education in a timely manner regarding emerging I-O clinical information to the multidisciplinary team
Our program is well-equipped and staffed to handle immune-related Adverse Events (irAE)
Our program facilitates tumor board and multidisciplinary team meetings to discuss indications for and potential benefits of immuno-oncology agents for specific patients
7. With regards to nurse care coordination for I-O patients, please select the top three challenges?
Required
8. Please share you program top three challenges/concerns as you prepare to implement or improve your immuno-oncology program. (e.g. Management of irAEs, Care Coordination, Coverage and Reimbursement, Practice Operation Issues, Medication Safety, Inventory)
Your answer
9. Please share any other key topics or concerns that you would like the ICLIO Visiting Experts faculty to include in your workshop?
Your answer
10. Please provide the name, title, email, and phone number of the clinician/team member in your program who will serve as the “champion” for this program. (The champion will play the key role in interacting and coordinating plans with the ICLIO project team.)
Your answer
Thank you for your interest in participating in the ICLIO Visiting Experts program. You will be notified in January 2017 when a decision has been made.
A copy of your responses will be emailed to the address you provided.
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