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Service Delivery Innovation Profile

Community-Based Oncology Practice Redesigns Processes Based on Patient-Centered Medical Home Model To Enhance Access, Improve Quality, and Reduce Costs


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Snapshot

Summary

A community-based oncology practice (Consultants in Medical Oncology and Hematology, PC) reengineered its care delivery processes using evidence-based frameworks, including the National Committee for Quality Assurance's patient-centered medical home model. Known as the Oncology Patient-Centered Medical Home® and supported by oncology-specific information technology, the redesigned process features practice accountability for all cancer-related care, standardized patient evaluations at each visit, multidisciplinary care plans, patient navigators who arrange and track externally provided care, a telephone advice and triage line, various activities to educate and engage patients, and ongoing performance monitoring and improvement. The program has led to strong or improved performance on multiple measures of access, quality, and efficiency, including patients' ability to come in for unscheduled visits (a measure of access), clinician adherence to chemotherapy guidelines, complication-related symptoms, survival rates, end-of-life care, emergency department and inpatient use, and costs of care. In 2010, the practice achieved recognition as a patient-centered medical home from the National Committee for Quality Assurance.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of unscheduled patient visits, complication-related symptoms, end-of-life care, emergency department visits, and inpatient admissions, along with post-implementation data on adherence to chemotherapy guidelines, survival rates, and estimated cost savings generated by the program.
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Developing Organizations

Consultants in Medical Oncology and Hematology, PC
Drexel Hill, PAend do

Date First Implemented

2010
The practice became a medical home in April 2010.

Problem Addressed

The delivery of medical care, including cancer care, is often fragmented, with deficiencies in communication, care coordination, and accountability.1 The patient-centered medical home (PCMH) model has been shown to address these problems in primary care, yet to date few specialty practices (including oncology practices) have adopted this approach.
  • Fragmented care: The delivery of medical care, including cancer care, is highly fragmented,  characterized by poor communication across providers, duplication of services, low adherence to clinical guidelines and other standardized care processes, lack of teamwork, unnecessary delays, inadequate patient education (leading to patient confusion about treatment plans), incomplete medical records, and unclear accountability among providers.1 Care fragmentation is particularly problematic in oncology, as cancer patients tend to be older and chronically ill and often have multiple co-occurring conditions and unique psychosocial needs that make them a particularly vulnerable population.1
  • Significant benefits of PCMH in primary care settings: Results from demonstration projects conducted in primary care settings suggest that the PCMH model can have a positive impact on quality, costs, and patient and provider satisfaction.2 For example, a study of almost 4,000 patients with various chronic conditions found that those treated according to PCMH principles fared better than those receiving usual care.2 Patient-centered medical homes have also been shown to reduce costs; for example, a PCMH initiative in North Carolina saved $244 million.2
  • Failure to apply to oncology care, despite likely benefits: The PCMH model can likely be effective in specialty settings, particularly in medical oncology practices that are increasingly responsible for coordinating complex treatment plans, providing case management, educating patients, communicating with other physicians, managing palliative and end-of-life care, and tracking care electronically.1 Few if any oncology practices have adopted the model or are in the process of doing so, however.

What They Did

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Description of the Innovative Activity

Consultants in Medical Oncology and Hematology, PC, reengineered its care delivery processes using evidence-based frameworks, including the National Committee for Quality Assurance's (NCQA's) PCMH model. Known as the Oncology Patient-Centered Medical Home® and supported by oncology-specific information technology (IT), the redesigned process features practice accountability for all cancer-related care, standardized patient evaluations at each visit, multidisciplinary care plans, patient navigators who arrange and track externally provided care, a telephone advice and triage line, various activities to educate and engage patients, and ongoing performance monitoring and improvement. Key program elements are outlined below:
  • Oncology-specific IT to facilitate standardized care: The practice uses oncology-specific IT to facilitate the provision and documentation of standardized care, enhance communication among providers and between providers and patients, and monitor and improve quality.
    • Oncology-specific electronic medical record (EMR): An externally developed, oncology-specific EMR allows clinicians to document and track patient care. Embedded within the EMR are treatment plans based on clinical recommendations from the National Comprehensive Cancer Network and the American Society of Clinical Oncology, thus ensuring that physicians recommend chemotherapy regimens and other treatments supported by clinical evidence. The EMR is fully integrated with the laboratory, radiology, pathology, and medical record departments within the practice’s affiliated hospitals, allowing physicians immediate access to up-to-date information on inpatient care received by the patient.
    • Associated documentation tool: An internally developed tool (called Iris) pulls critical summary information from the EMR and presents it on a one-page scrollable document that forms the physician’s progress note. By highlighting acute clinical issues and gaps in care, the tool facilitates the provision of standardized care during visits. The tool also allows real-time documentation via speech recognition technology and permits auto-fax or auto–e-mail dissemination of documentation to the patient’s primary care physician and other specialists. Patients can access their Iris progress notes via a password-protected patient portal.
  • Accountability for all cancer-related care: Once a patient joins the practice, the practice assumes primary responsibility for coordinating all cancer-related diagnostic testing and treatment services and activities for that patient until he or she reaches the survivorship phase of care or requires end-of-life care. The patient's primary care physician is a valuable and involved member of the care team who receives frequent communications from the practice and referrals for management of comorbid conditions.
  • Standardized patient evaluation: A standardized evaluation occurs at each visit. This process involves the patient completing an assessment form, nurses evaluating the patient's health status, and physician's evaluating and managing all active clinical issues, as outlined below:
    • Patient assessment: At the start of each visit, a patient reviews a form that lists information pulled from the EMR, including demographic, insurance, and pharmacy data; emergency contacts; date of last hospitalization and emergency department (ED) visit; and date of last mammogram, colonoscopy, and other age- and gender-appropriate cancer screenings. The patient makes any necessary corrections and notes whether he or she had been admitted to a nursing home or transitional care facility and/or treated by any specialists since the last visit. Last, the patient rates the severity of any symptoms (e.g., nausea, vomiting, pain, night sweats, insomnia, weakness) on a scale of 1 to 10.
    • Nurse-led evaluation: The nurse reviews the form and discusses any changes with the patient. The nurse assesses vital signs, symptoms, performance status (measured by the Eastern Cooperative Oncology Group [ECOG] performance status score,3 which ranges from 1 [fully active] to 5 [death] and is used to evaluate patient health and ability, inform treatment decisions, and prompt end-of-life care discussions), and medication reconciliation results and documents all information in the oncology EMR, which is exported to the Iris progress note.
    • Physician evaluation: The physician uses Iris during the evaluation of the patient. The physician reviews prepopulated data (e.g., patient assessment, performance status, diagnostic test results). The screen highlights any out-of-range values, due or overdue immunizations, and significant changes from the previous visit to ensure that the physician addresses all active clinical issues.
  • Multidisciplinary care plan: During each visit, the physician and patient discuss potential treatment options and/or adjustments and, as appropriate, goals of therapy and end-of-life wishes. The physician generates or updates a multidisciplinary care plan based on changes in the patient's health status and performance status, the agreed-upon treatment approach, required referrals, patient goals for therapy, and preferences related to palliative and end-of-life care. Internal team members who may be involved in executing the plan include physicians, oncology nurse practitioners, physician assistants, chemotherapy nurses, patient navigators (see bullet below), a therapist who treats lymphedema (localized fluid retention and tissue swelling), psychologists, and a yoga instructor. The system automatically generates referrals to internal colleagues and faxes or e-mails reports to external referring and consulting physicians. External physicians with access to the system receive e-mail notification that a patient report has been generated, allowing them to view the report via an external physician portal.
  • Patient navigators who arrange external care: Patient navigators coordinate all aspects of external cancer care specified by the plan. Navigator tasks include gathering all clinical data from external sources, scheduling diagnostic testing ordered by the oncologist, and arranging necessary appointments with the patient’s primary care physician and other specialists (e.g., surgeon, radiation oncologist, mental health provider, physical therapist). The EMR alerts the navigator when diagnostic test results have not been received within the expected time frame, allowing them to contact the testing center and the patient. Navigators also connect patients to needed support services and other community-based resources.
  • Advice and triage line: Patients have access to the practice’s clinicians via a telephone triage line, and team members actively encourage them to call the line with questions and concerns as they arise. Patients can call between 8:00 am and 6:00 pm Monday through Friday to discuss symptoms and concerns with a nurse, and can reach an on-call physician at all other times. Triage nurses access the patient’s EMR during the call and use standardized symptom management algorithms to assess clinical issues. Depending on the specific circumstances, nurses provide advice over the telephone to help patients manage their symptoms at home, advise them to come in for an office visit, or recommend a trip to the ED. To date, more than 75 percent of calls have resulted in home-based management of symptoms.
  • Patient education and engagement: To encourage patient self-management, physicians and nurses provide personalized education during visits, including information about the disease, treatment options (e.g., risks, benefits, and likely outcomes), and the importance of adherence to the treatment regimen. Patients also receive packets of written educational materials specific to their disease and treatment options. To promote patient engagement, team members encourage patients to prepare questions for the doctor before the visit, ask as many questions as needed during the visit, and call the triage line to report symptoms and concerns promptly. As stated earlier, patients also have access to the physician’s progress notes and treatment plan via a patient portal, thus further encouraging engagement.
  • Ongoing performance monitoring and improvement: The Iris system automatically generates data on performance over time for a set of indicators, including but not limited to hospitalizations, ED visits, success of symptom palliation, and disposition of triage calls. During monthly meetings, physicians review performance on these indicators and share best practices. Trends in performance inform the development of quality/process improvement initiatives.

Context of the Innovation

Consultants in Medical Oncology and Hematology, PC, provides hematology and oncology care to patients in southeastern Pennsylvania. The practice, which includes 4 offices that are affiliated with 2 hospital systems (Crozer-Keystone and Main Line Health Systems), treats approximately 6,000 patients each year. Roughly one-half of patients have commercial insurance/managed care, 40 percent are on Medicare, and 10 percent receive medical assistance (i.e., Medicaid) from the state.

The roots of the practice’s quest for performance measurement and improvement date back to the late 1990s, when the push for integration and consolidation in the Philadelphia area health care market created a focus on the ability to share data across sites. Dr. John Sprandio, the practice’s president, began considering how to improve data sharing within the practice. In 2003, the practice adopted an EMR, after which practice leaders began looking for ways to maximize the ability of the EMR to promote quality and efficiency. It became clear that achieving these goals required a thorough review and redesign of the practice's care processes. Leaders decided to embark on a major reengineering effort, with the goal of streamlining and standardizing care; maintaining a patient-centered approach; minimizing clinically irrelevant physician activity; and improving communication, coordination, access, and patient engagement. By 2008, the practice’s physicians realized that the process enhancements that had been made over time reflected the elements of a medical home, and hence they decided to apply for recognition as a PCMH from NCQA. The practice received this designation in April 2010.

Did It Work?

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Results

The PCMH model has led to strong or improved performance on multiple measures of access, quality, and efficiency, including patients' ability to come in for unscheduled visits, clinician adherence to chemotherapy guidelines, complication-related symptoms, survival rates, end-of-life care, ED and inpatient use, and costs.
  • More unscheduled visits, suggesting better access to care: Indicative of improvements in access to care (reflecting the number of patients who are seen promptly by the practice, despite the absence of a scheduled appointment), the number of unscheduled patient visits occurring within 24 hours of a telephone triage line call increased from 197 in 2007 to 352 in 2011.
  • Strong adherence to chemotherapy guidelines: Adherence to guideline-based care plans for chemotherapy reached 96 percent in 2011.
  • Fewer complication-related symptoms: Since implementation of the program, complication-related symptoms have declined, including the incidence of Clostridium difficile enteritis (as evidenced by a 50-percent decline in admissions for treatment of this condition) and delayed posttreatment- and chemotherapy-induced nausea. The latter improvement was evident in declines in the use of oral 5-hydroxytryptamine 3 inhibitors; the annual number of new prescriptions fell from 112 to 20 and refills fell from 86 to 6 between 2005 and 2010.
    • High survival rates: The practice has 1-, 2-, 3-, 4-, and 5-year survival rates (all-cause mortality rates) that are within the national average for patients with Stage III colorectal, breast, and lung cancer.
    • Better end-of-life care: Several measures suggest improvements in end-of-life care, including increases in the average length of hospice stays (from 26 days in 2009 to 35 days in 2011), declines in the proportion of patients visiting an ED (from 23.9 percent in 2010 to 20.1 percent in 2011) or admitted to the hospital (from 39.3 percent in 2010 to 36.4 percent in 2011) in the last 30 days of life, and an increase in the proportion of patients dying at home (from 70 percent in 2010 to 74 percent in 2011).
    • Fewer ED visits and hospitalizations: The number of ED visits per chemotherapy patient per year for a patient on active treatment fell from 2.6 in 2004 to just over 0.8 in 2011. The percentage of calls to the triage line that resulted in an ED referral fell by more than 50 percent between 2005 and 2009, from 11.85 to 5.06 percent, even as patient volume grew by 30 percent. Between 2005 and 2009, the annual number of inpatient admissions for practice patients fell by 16 percent (from 435 to 340), with an additional 9.7-percent decline in 2010. Average admissions per chemotherapy patient per year fell by more than 50 percent between 2007 and 2011, from 1.080 to 0.528.
    • Significant cost savings: A 2010 analysis estimates that the PCMH model has generated more than $9 million in savings to payers per year, including $8.9 million from reduced hospital admissions and $607,000 from reduced ED use. This figure translates into $12,000 in savings for each chemotherapy patient. Overall cancer care costs are estimated to have decreased by 6.6 to 12.7 percent as a result of the program.

    Evidence Rating (What is this?)

    Moderate: The evidence consists of pre- and post-implementation comparisons of unscheduled patient visits, complication-related symptoms, end-of-life care, emergency department visits, and inpatient admissions, along with post-implementation data on adherence to chemotherapy guidelines, survival rates, and estimated cost savings generated by the program.

    How They Did It

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    Planning and Development Process

    Selected steps included the following:
    • Purchasing EMR and interfacing with affiliated hospitals: The practice purchased an oncology-specific EMR in 2003. By January 2005, all four practice sites had become paperless, with the EMR able to interface with IT systems at affiliated hospitals.
    • Selecting indicators to track: The lead physicians and practice administrator reviewed clinical guidelines to identify best practices, define quality parameters, and select clinical and financial metrics to monitor on an ongoing basis.
    • Selecting care processes to standardize: The physicians reviewed care processes and considered which ones to standardize so as to improve quality and reliability.
    • Developing Iris: In 2004, the practice’s IT staff developed Iris as an “overlay” that could pull relevant information from the EMR to enhance ease of use and the ability to improve quality and efficiency.
    • Pursuing medical home designation: In 2008, Dr. Sprandio learned from a colleague that the practice’s services and approach dovetailed nicely with the components of an NCQA PCMH. Practice leaders reviewed NCQA's PCMH criteria to determine what components might be missing. The practice developed these components and applied to NCQA for medical home recognition.
    • Negotiating better rate with payers: The practice monitored reductions in utilization as a result of the program and associated cost savings for payers, and contacted its large commercial payers to advance this model as a new value proposition in negotiations.
    • Retraining administrative staff for navigator role: In 2009, the practice determined that patient navigators were a necessary element for achieving medical home designation. The practice added the position in 2009, along with an automated voice recognition system that reduced the need for transcription. As a result, administrative assistants could be retrained to become patient navigators.

    Resources Used and Skills Needed

    • Staffing: The new care process required no new staff, as existing staff incorporate it into their daily routines. In fact, the PCMH model and associated streamlining of care has allowed the practice to reduce staffing by between 10 and 11 full-time equivalent (FTE) positions through attrition. The practice now has 9 physicians and more than 75 full- and part-time staff (equivalent to approximately 50 FTEs), including oncology nurse practitioners, physician assistants, nurse managers, chemotherapy nurses, patient navigators, and others.
    • Costs: Information on the costs of developing this program is not available. As noted, the program has generated cost savings on an ongoing basis.
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    Funding Sources

    Consultants in Medical Oncology and Hematology, PC
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    Tools and Other Resources

    Two organizations are facilitating the dissemination and spread of the oncology-specific PCMH model.
    • Founded by John Sprandio, MD, president of Consultants in Medical Oncology and Hematology, PC, Oncology Management Services, Ltd. (http://www.oms-support.com) helps community-based oncology practices adopt the model. Interested practices may contact info@opcmh.com to obtain information regarding its comprehensive toolkit and technical support.
    • The Community Oncology Alliance, a Washington, DC–based advocacy group, is using the model as a template to help other community-based practices shift to a medical home model. More information is available at: http://www.communityoncology.org/site/medical-home-aco.htm
    Information about becoming recognized as a PCMH by NCQA is available at: http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx.

    Oncology clinical guidelines are available from the following:

    Adoption Considerations

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    Getting Started with This Innovation

    • Secure physician support: The lead physicians at the practice secured their colleagues’ “buy-in” for standardized care processes by emphasizing the positive impact the program would have on quality, physician efficiency, and practice sustainability.
    • Emphasize structured fields in IT tools: Data entered into structured fields (rather than as free text) can be easily searched and used to monitor performance on various indicators on an ongoing basis, thus facilitating quality improvement.
    • Standardize based on evidence: Base all practice standards on clinical evidence related to best practices. Design written policies and procedures that reflect these standardized processes.

    Sustaining This Innovation

    • Negotiate with payers to share in savings: Practices adopting this model may develop new programs (such as a telephone triage line) that improve quality but do not qualify for reimbursement on their own and that may reduce the need for reimbursable services such as office visits. As a result, practices adopting this model may suffer financially unless payment models are revamped. To that end, would-be adopters should contact payers to discuss development of shared-savings programs, pay for performance/value, or other payment methodologies that reward practices financially for improving quality and reducing costs and utilization.
    • Monitor performance to facilitate continuous improvement: Practices should continually monitor performance on key indicators, using the information to inform improvement efforts. For example, tracking the content of patient calls to the triage line may reveal symptoms that could be better managed on a population basis. Consultants in Medical Oncology and Hematology, PC, enhanced its services (e.g., by adding certain medications to treatment protocols) based on information about the frequency of patient symptoms.

    Spreading This Innovation

    Oncology Management Services, Ltd. is currently working with six practices interested in becoming oncology medical homes.

    More Information

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    Contact the Innovator

    John Sprandio, MD
    Principal
    Oncology Management Services
    Consultants in Medical Oncology and Hematology, PC
    2100 Keystone Avenue, Suite 502
    Drexel Hill, PA 19026
    E-mail: jsprandio@cmoh.org

    Susan Tofani
    Director, Payer and Network Relations
    Oncology Management Services
    Consultants in Medical Oncology and Hematology, PC
    2100 Keystone Avenue, Suite 502
    Drexel Hill, PA 19026
    (215) 817-7957
    E-mail: stofani@oms-support.com

    Innovator Disclosures

    Dr. Sprandio is the principal of Oncology Management Services, and thus has a financial interest in the company. Ms. Tofani is a consultant to Oncology Management Services and her compensation is tied to company performance.

    References/Related Articles

    The Advisory Board Company. Inside the first NCQA-designated medical oncology medical home. August 11, 2010. Available at:
    http://www.advisory.com/Research/Health-Care-Advisory-Board/Blogs/The-Blueprint/2010/08
    /Inside-the-first-NCQA-designated-medical-oncology-medical-home
    .

    Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Community Oncology. 2010;7(12):565-72. Available at:
    http://www.communityoncology.org/UserFiles/pdfs/co-js-medical-home.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

    George J. Oncologist bringing medical home model to cancer docs. Philadelphia Business Journal. June 15, 2012. Available at:
    http://www.bizjournals.com/philadelphia/print-edition/2012/06/15
    /oncologist-bringing-medical-home-model.html?page=all
    .

    Footnotes

    1 Sprandio JD. Oncology patient-centered medical home and accountable cancer care. Community Oncology. 2010;7(12):565-72. Available at: http://www.communityoncology.org/UserFiles/pdfs/co-js-medical-home.pdf.
    Comment on this Innovation

    Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

    Original publication: January 30, 2013.
    Original publication indicates the date the profile was first posted to the Innovations Exchange.

    Last updated: May 21, 2014.
    Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

    Date verified by innovator: December 26, 2013.
    Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.