From angst to analytics: lessons learned from an oncology care model internal pilot
Thirteen practices affiliated with the US Oncology Network (USON) were invited to participate in the Oncology Care Model (OCM), a value-based care initiative that required changes in the following domains: 24/7 coverage, electronic health records (EHR) certification, navigation and care coordination, continuous quality improvement, incorporation of the Institute of Medicine Care Plan, and adherence to nationally recognized guidelines. Although 24/7 physician coverage, access to EHR, and adherence to guidelines were routine for these practices, the other requirements represented significant challenges. To be prepared for this transformative opportunity, USON implemented a pilot program 4 sites 6 months before participation began to identify the practice changes that would be needed to meet OCM requirements with the goal of standardizing best practices that would be shared with other USON sites. Through the pilot, the practices developed team-based approaches for navigation, the treatment plan, team-based care, and a core technology platform to address extensive OCM documentation requirements. An ongoing challenge is addressing the cultural resistance to change, which can hopefully be addressed with data and outcomes. Unexpected findings included the difficulty in identifying eligible candidates, a need to increase emphasis on adherence to national guidelines, and a need for strategies to reduce hospitalizations and emergency department visits. The pilot program showed that several seemingly challenging aspects of the OCM were feasible and areas for improvement were identified for improving the patient experience while decreasing the cost of cancer care.
Accepted for publication September 14, 2017
Correspondence Marcus A Neubauer, MD; Marcus.Neubauer@Mckesson
Disclosures The authors report no disclosures/conflicts of interest.
Citation JCSO 2017;15(6):e297-e302
©2017 Frontline Medical Communications
doi https://doi.org/10.12788/jcso.0371
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Communications, Revenue Cycle, and Incentives
The final work stream was Communications, Revenue Cycle, and Incentives. For the pilot, the focus was on revenue cycle. A new category of patient needed to be identified, enrolled, and billed to CMS for services. At the outset, the technology did not address the identification of patients receiving only oral drugs. The office visit, the diagnosis, and the drug claim all had to be aligned for enrollment and billing. It was critical to understand the workload by patient and total volume to estimate the technology and personnel needs to meet the initial number of new OCM patients. Communication refers to both internal and external parties. Education of the entire practice staff regarding transformation will be critical for success.
Of the 12 participating practices, 3 practice sites were selected for the pilot program. Each had fewer than 10 medical oncologists and at least 1 radiation oncologist. Each site had a physician champion and an administrative lead. All of the sites were part of a larger regional oncology practice. A fourth site had independently started a pilot and that experience was shared with the larger group as well. The sites were distributed across the country in 4 different time zones.
The pilot experience
The pilot experience yielded important findings, some expected and some unexpected. The challenges of navigation, the treatment plan, and team building were anticipated. We were surprised at the sheer number of potential candidates and the difficulty in finding eligible candidates. Not to be overlooked was a need for continued and possibly increased emphasis on adherence to pathways and process changes to reduce hospitalizations and emergency department (ED) visits.
Navigation
At the outset, none of the pilot practices had formal navigation processes as outlined in Table 1. Many of the processes, such as coordinating appointments and facilitating follow-up services and financial support, were provided by the practice, but were not identified or coordinated as navigation. The practices, as a first step, defined who was responsible for those services and identified 1 person who would be responsible for their completion. It was agreed that navigation was a process shared by a team and not an individual responsibility, yet the person who would monitor the completion of the tasks was not identified. It soon became apparent that true navigation included more tasks than initially outlined.
Additional tasks included appropriate patient education regarding treatment toxicities, follow-up after chemotherapy or a hospitalization, and coordination of other aspects of the IOM care plan, such as survivorship and advance care planning. Each of the practices recruited staff internally to assume the navigator role, and standard operating procedures were developed for completing and documenting this expanded responsibility. True navigation, however, depends on building the team character while still having 1 or 2 members of the team identified as being responsible for following and documenting the patient’s journey through an episode. To meet those needs, navigators developed ad hoc methods, such as spreadsheets, to track patients. The technology team developed drop-down check lists within the EHR, but the burden of documentation continued. Lastly, an ongoing challenge is how best to designate responsibility and assess how many additional staffers are needed.
IOM Care Management Plan
Before initiation of the pilot project, no practice was providing patients with a comprehensive, written treatment plan. Considerably more than half of the members of the work-stream teams believed that would be difficult to implement. However, the members of the Care and Support work stream made some fundamental assumptions to make the care plan workable: first, all aspects of the plan did not occur at the same time, and were not completed by the same person; second, and critically, items 2-9 of Table 2 could be completed at one time during the early conversations between the physician and patient about the goals of treatment. Diagnosis, prognosis, treatment intent, response rate, quality of life, and toxicities were included in the treatment plan, and the remaining IOM care plan could be discussed, or at least identified, as issues for further discussion with other team members. These components were incorporated into a 1-page document that was either typed into the record and printed out or handwritten and copied for the patient. This became the treatment plan and was ready for use at the start of the pilot.
The physician response to the treatment plan was mixed. One site adopted it enthusiastically and quickly moved to use the plan for all patients. Other sites had variable uptake. One hurdle was defining response rate to therapy and prognosis. Data were provided but they often did not match the conditions of individual patients. Some physicians were uncomfortable with the process. Documentation was difficult because the plans had to be scanned into the EHR. Patients generally responded favorably to the plans and would bring them to teaching or chemotherapy sessions.
As with navigation, the treatment plan challenges pointed the technology team toward the development and implementation of an electronic version of the plan. The pilot allowed members of the technology team to visit the clinics, to evaluate workflows and make assumptions on how to structure a treatment plan electronically.
