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
Submit a paper here
Team-based care
None of the pilot sites had a formalized structure for team-based care. Team huddles were developed and weekly and daily huddles were encouraged. The weekly huddles took about 15-30 minutes, during which patients scheduled for the coming week were reviewed. All personnel who saw patients were invited – benefit counselors, advanced practice providers, schedulers, lab technicians, medical assistants, office and infusion nurses, social workers, pharmacists, physicians, and lead administrative staff. The daily huddle was smaller and generally included a nurse, a medical assistant, and a physician, at a minimum, to review the patients in the hospital, those to be seen in the clinic that day, and any follow-up information based on scheduled contact following recent treatments or events. In some sites, these huddles were uniformly endorsed, in others, not at all. Although many physicians felt that the functions were being handled informally and the additional time commitment would not improve the process, once they began to attend the meetings, they appreciated the value of the huddles and continued attending them. As the complexity of delivery and documentation becomes more apparent, these will prove indispensable to coordinated care.
24/7 access
Hospitalization is one of the chief drivers of the total cost of care, so the pilot sites were concerned that more needed to be done to reduce unnecessary hospitalizations. One site surveyed the patients coming into the clinic about their previous ED visits. Many of the visits had been for noncancer-related events and the clinic was not aware of many of the many of the visits. These findings prompted a number of changes. Open slots were created daily for patients who needed to be worked in for any areas of concern. The on-call physician, triage nurse, or navigation lead could fill these slots. All patients discharged from the hospital were called within 48 hours after discharge and scheduled for a clinic visit within 1 week. Night and weekend call logs were scrutinized each morning and patients’ calls were returned for any issues related to symptom or toxicity management. At one site, patients were given wallet cards with the clinic number, the treatment regimen, and, on the reverse, all symptoms that would justify calling the clinic. The patients were encouraged to call the clinic earlier rather than later in the day. On the back end, the clinics were to have processes in place so that patient calls would be answered quickly to facilitate same-day evaluations in the clinic.
Enrollment and revenue cycle
The most intractable problem was the identification and enrollment of OCM patients. As already noted, 3 components were necessary for enrollment: a drug charge for Part B or D Medicare, a provider visit, and an approved cancer diagnosis. To identify those patients, the claims system would churn out a weekly list of all eligible patients. However, the claims system had no mechanism to pick up Part D claims for oral medications. This meant that any patient with a provider visit and an appropriate diagnosis was potentially eligible for enrollment. At one site, the list of potential patients was 2-3 times the number of actual candidates. It took 6 weeks of manual chart review to resolving the list. Collectively, the 12 practices could have as many as 20,000 patients eligible for the July 1 enrollment. The pilot allowed the practices to get an early start on recruitment of business office staff and plans to address the backlog of potentially eligible patients. The process of identifying eligible patients for the OCM still needs a better solution because finding the appropriate patients is a critical first step in this model.
Underlying all of these initiatives is communication, both internal and external. We have to select and celebrate best practices. We have to educate our staffs. We will have to demonstrate that we are giving better care to our patients by using patient and provider testimonials and data.
From angst to analytics
The challenges of practice transformation can be daunting. It will be difficult to formalize processes and document data in ways that were untested before the pilot program was set up. However, the pilot accomplished 2 things: it identified additional areas that needed improvement and it demonstrated that the most challenging aspects of the OCM were feasible. Navigation and the IOM care plan were broken down into parts; each component was separately addressed, and programs were put in place to make the pieces manageable and part of an overall movement toward team-based care. The addition of a technology platform has been a key factor for the success of the value-based care initiative. Additional technology support has been enlisted to facilitate the processes, and an electronic version of the treatment plan is being tested. More difficult will be efforts to address the cultural resistance to change, which we hope to do by using data and outcomes from the CMS claims data files. The OCM represents an unprecedented opportunity for measurement of the quality of care we deliver.
