Oncology Patient-Centered Medical Home and Accountable Cancer Care John D

How We Do It

Oncology patient-centered medical home and accountable cancer care John D. Sprandio, MD Consultants in Medical Oncology and Hematology, PC, Drexel Hill, PA

With the passage of healthcare reform and the call for improved quality, value, and demonstration of results, the primary care patient-centered medical home (PCMH) concept has gained considerable traction across the United States. In 2004, we began re-engineering our processes of cancer care delivery in our medical oncology practice concurrently with the implementation of an oncology-specific electronic medical record and the development of customized software to better suit practice/patient needs and to facilitate data collection. These custom software applications were designed to support comprehensive processes of care that were also required for level III medical home recognition by the National Committee for Quality Assurance (NCQA). We have been tracking our data for the past 5 years, documenting improvements in disease management—notably the reduction in emergency room utilization and hospital admissions. We have engaged local and national payers with the goal of developing collaborative pilot programs. Furthermore, we are establishing formalized relationships with other like-minded medical oncology and primary care PCMH practices, as we continue to refine our delivery of cancer care within an oncology PCMH model.

edical oncologists are A backward glance at care for patients across the continu- playing an ever-ex- the PCMH model um, improve the coordination of care, panding role in the A combination of factors has led to establish a standardized comprehen- delivery of cancer care. the rapid acceptance •of the PCMH sive process of care, adhere to estab- The current and future challenges they model in the delivery of primary care: lished practice guidelines, utilize a faceM in their efforts to deliver effective, (1) physician and patient recognition care-team approach, engage and edu- efficient, and appropriate cancer care of the PCMH model as a partial so- cate patients to enhance involvement are broad, and solutions to the rising lution to the unacceptable fragmen- in their care, and create innovative costs of cancer care continue to be tation of healthcare delivery; (2) the ways of communicating with all par- sought. The patient-centered medical availability of electronic medical re- ties involved. home (PCMH) model has emerged cords (EMRs) and the actionable in- as a partial solution to the fragment- formation that can be mined from EMR systems ed delivery of primary healthcare. In clinical databases; (3) the alignment When fully implemented and en- many instances, the delivery of can- of incentives among stakeholders, in- hanced, EMR systems have the poten- cer care is also fragmented—fraught cluding the largest employers in the tial to promote a culture of continuous with deficiencies in communication, United States, medical professional improvement that creates practice effi- coordination, and accountability. The societies, consumers, insurance com- ciencies. Furthermore, EMRs can po- oncology PCMH (OPCMH) model panies, academic institutions, patient tentially allow physicians to concen- of cancer care may potentially serve advocacy groups, state Medicaid agen- trate on their primary responsibilities as a practice framework for oncolo- cies, and the Centers for Medicare & of making complex medical decisions gists. The OPCMH model attempts Medicaid Services; and (4) early re- based on real time, evidence-based to promote a value-based agenda sults from medical home demonstra- data while establishing and maintain- that facilitates physician accountabil- tion projects, suggesting that elements ing personal relationships with their ity, encourage clinical integration be- of the model may have a positive ef- tween like-minded medical oncology fect on quality, cost, and satisfaction of Manuscript received November 16, 2010; ac- groups, enhance communication and the patient and clinical team.1,2 cepted December 3, 2010. coordination of care with primary Correspondence to: John D. Sprandio, MD, care PCMH models, and collaborate Unacceptable fragmentation of care Consultants in Medical Oncology and Hema- tology, PC, 2100 Keystone Avenue, Suite 502, with payers while maintaining a focus In order to address the fragmen- MOB, Drexel Hill, PA 19026; telephone: 610- on patient needs and evidence-based tation of care, there are a number of 622-3818; fax: 610-622-6407; e-mail: jsprandio care. actions that physicians should take: @cmoh.org. © 2010 Elsevier Inc. All rights reserved. Commun Oncol 2010;7:565–572

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TABLE 1 patients. Customized software can allow for streamlining and standard- The expanding role of the medical oncologist izing care, tracking multiple disease n Coordinate complex multimodality n Have increasing on-demand patient management data points in patients treatment plans access to care with co-morbid conditions, and fa- n Adhere to established treatment n Proactively address complications of cilitating the identification and mea- guidelines disease and treatment surement of potential complications n Coordinate care n Track testing and appointment compliance of therapy and disease. n Assist patient navigation through care n Create specific disease registries n Case management n Develop and disseminate high-risk Alignment of interests n Educate patients patient databases The various stakeholders embrac- n Promote patient engagement n Create and execute survivorship care ing the medical home model of care n Improve documentation capabilities planning have specific interests and perspec- n Communicate with referring and n Plan end-of-life care tives. Their individual and collec- consulting physicians tive assessment of currently provided n Deliver and coordinate palliative care medical services is critical in mold- ing the future definition of value in and management services has simply deductibles dictated by the insurance healthcare. The value of the medical not kept pace with the complexity of industry. The current medical oncology home model in primary care is clear: tasks required of physicians in deliv- E&M (evaluation and management) by engaging more proactively with ering improved quality care. Virtu- payment schedule has not supported chronic disease patients to manage ally every payer nationally recognizes these expanding responsibilities, the symptoms and chart disease progres- this disconnect and is making adjust- current call for improvements in quali- sion over time, providers can reduce ments, including the consideration ty care, or the advancement of the con- acute events, thus decreasing resource of payment for the PCMH model in cept of value in cancer care. utilization while improving out- primary care. The healthcare reform legislation, comes. These same principles can be In many ways, the dilemma of the and many of the recently initiated applied to the delivery of cancer care, medical oncologist is the same as that programs in response to it, promotes where the financial and clinical stakes of the primary care physician.4 In the a critical focus on patient needs, value, are often higher. community-based oncology arena, quality, and results. The application of these problems have been exacerbated a PCMH model to cancer care fits Application of the PCMH by the perverse methodology of pay- very propitiously at this moment with model of care to oncology ing physician practices for the drugs healthcare reform. Patients with cancer currently re- they administer after discounts from An oncology patient- ceiving active treatment represent less pharmaceutical companies—a model centered medical home than 1% of the commercially insured that has eroded over the past several (OPCMH) in action population, but they account for ap- years. proximately 10%−12% of healthcare Historically, up to 85% of can- Consultants in Medical Oncology expenditures. The cost of cancer care cer care delivery was provided in and Hematology, PC (CMOH), pro- in the United States is rising at an un- community-based medical oncology vides hematology and oncology care sustainable rate of 15%−20% annual- practices.5 The previous reimburse- within three health systems in south- ly.3 In many instances, the delivery of ment model allowed medical oncol- eastern Pennsylvania. CMOH became cancer care is fragmented—fraught ogy practices to assume an increasing the first oncology practice in the na- with deficiencies in communication, degree of responsibility for navigat- tion to earn level III recognition from coordination, and accountability. In ing patients through the complex, the National Committee for Quality addition, patients with cancer gen- fragmented maze that all too often is Assurance (NCQA) under its Physi- erally tend to be a vulnerable, older, cancer care in this country. Medical cian Practice Connections−Patient- chronically ill population with multi- oncologists have played an ever-ex- Centered Medical Home (PPC− ple co-morbid conditions and unique panding role in the delivery of cancer PCMH™) program in April 2010. The psychosocial needs. care (Table 1). practice was recognized for using in- The financial plight of the prima- More recently, oncologists have formational systems to measure prac- ry care physician is well known and been asked to provide financial coun- tice-wide clinical quality parameters long-standing. It is widely recognized seling to address the spiraling cost of and for improving clinical outcomes at that reimbursement for evaluation drugs and the rising co-payments and the point of care.

566 COMMUNITY ONCOLOGY ■ December 2010 www.CommunityOncology.net n The PPC−PCMH program iden- Increased patient access and en- services is the re-engineered process tifies practices that promote partner- hanced communication of care and the customized software n ships between individual patients Patient tracking and registry func- enhancements necessary to support and their personal physicians, rather tions, including reminders for preven- them. Software was developed to bet- than episodic office visits for patient tative screenings ter suit physician, patient, and prac- n care. Each patient is tended to by a Care management and adher- tice needs to format, standardize, and physician-led care team. The cur- ence to nationally accepted, evidence- collect critical patient management rent OPCMH model being devel- based standards of treatment and utilization data. n oped by CMOH is straightforward. Patient self-management and sup- Cancer care is plagued by com- At the time of the diagnosis of can- port as a strategy for avoidance of munication and coordination gaps, cer, the practice assumes the prima- potential complications of treatment commonly exposing patients to con- ry responsibility for the coordination and disease flicting information, duplicate pro- n of all related services for patients re- Electronic prescribing and physi- cedures, confusion about treatment quiring evaluation and active treat- cian ordering plans, unanswered questions, and in- n ment of their oncologic and hema- Test tracking and monitoring pa- complete medical records.7 It is gen- tologic conditions. Responsibility of tient compliance erally understood that the ability of n care delivery continues through all Referral tracking current EMR software to support n necessary therapy—including sur- Continual performance reporting data collection and coordination of gery, radiation therapy, and chemo- and improvement care is suboptimal. EMRs have not n therapy—and extends into the sur- Advanced electronic communica- been designed to readily move in- vivorship phase of care. The practice tions including a portal for patients formation between sites. As a result, does not assume the management of and referring physicians. patient records are commonly inac- nononcologic medical issues from Oncology-specific PCMH goals. To cessible to referring and consulting the patient’s primary care physician, apply the PCMH model to cancer physicians.8 Coordination of care is necessitating the maintenance of an care, CMOH focused on the follow- not only essential for delivering qual- intense level of communication being aspects of care delivery: ity in cancer care, it is also a prereq- n tween the practice and the primary Streamline and standardize the uisite for maintaining and expanding care team. The OPCMH model of process of patient evaluation in the lines of referral.9 care essentially provides a frame- medical oncology office Listed below are OPCMH soft- n work for defining and refining the Coordinate all aspects of cancer- ware and process enhancements: n concepts of quality and value in can- related evaluations and services be- IRIS oncology physician docu- cer care. yond the medical oncology office via mentation tool: CMOH began to re-engineer its patient navigators 1. Immediate completion of stan- n processes of care in 2004. By January Proactively promote an interdisci- dardized documentation 2006, all four offices had transitioned plinary approach to management 2. Timely communication with n to paperless operations. Practice IT Constantly collaborate between autofaxing or EMR interfaces capabilities were fully interfaced with the clinical support and treatment 3. Physician document manage- the laboratory, radiology, pathology, teams ment review program n and medical record departments of all Stress the importance of patient 4. Referring/consulting physician affiliated hospitals. education, engagement, and compli- portal access The IT infrastructure and the pro- ance 5. Recorded symptoms as a n cesses of care evolved, allowing for the Enhance patient access to allow prompt in the IRIS documentation creation of a unique spectrum of pa- proactive management of symptoms software, ensuring all active clinical tient services that enhanced the level via extended hours, telephone triage issues are addressed of coordination of care and the col- services, and physicians on-call 6. Standardized nursing assess- n lection and evaluation of clinical data. Minimize clinically irrelevant ment and documentation of patient This cycle of data collection and eval- physician activity symptoms and ECOG (Eastern Co- n uation fuels continuous improvement Fix accountability for care delivery operative Oncology Group) perfor- within the practice. at the physician-patient locus mance status, verified by the physician n NCQA medical home recognition re- Assume ownership of cancer-relat- 7. Current and longitudinal data quirements. To achieve level III recogni- ed needs in a highly personalized way. presented to the physician at the time tion, the practice satisfied the following Customized software. The key to the of the visit nine standards outlined by the NCQA6: execution and delivery of OPCMH 8. Assessment and plan autopop-

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ulated with active clinical issues tient- and family-centered care doubled during a 5-year period (Fig- n 9. End-of-life-care discussions Guidelines for patients to become ure 2). prompted based on changes in disease partners in their own care: OPCMH chemotherapy patient ER and performance status 1. Prepare questions prior to their utilization. ER referrals for patients n Performance status and NCI (Na- appointments actively on treatment progressive- tional Cancer Institute)-graded re- 2. Ask questions until they under- ly decreased since 2004 (Figure 3). view of system tracking stand their situation and options The current practice average is less n Palliative care symptom manage- 3. Accept their responsibility to than one ER visit per patient per year ment report any and all symptoms early (Commercial, Medicare, and Medic- n Telephone triage system and data 4. Understand the concept of ear- aid populations included). This num- collection ly intervention, in relation to emer- ber compares favorably with ER uti- n Outside testing result and ap- gency room (ER) and hospital admis- lization rates of two per patient per pointment tracking and compliance sion avoidance year, reported in a large commercially n Customized patient education, 5. Utilize telephone triage system insured population.3 symptom management instructions and enhanced access to care OPCMH admission data. As n n Enhanced patient queuing and Become familiar with how to ac- CMOH developed and expanded tracking cess and use the features of the pa- OPCMH-related programs across n Unscheduled visit utilization tient portal. the practice, it documented a 16% re- tracking duction in overall hospital admissions n Positive results thus far Remote access to most recent in fiscal year 2009, with an addition- medication list and laboratory results CMOH has seen positive results al 9.7% reduction in fiscal year 2010 n Health screening and immuniza- since 2005. Particular areas of im- (Figure 4). tions tracking. provement in care follow: OPCMH symptom management OPCMH patient navigators. In OPCMH phone triage system. The standardization. CMOH has targeted addition to utilizing technologic re- campaign to make patients more in- a series of potentially avoidable com- sources and educational programs, volved in their own care has resulted plications and standardized the clini- CMOH also trained patient navi- in a dramatic increase in timely clinical assessment of complication-related gators to assist patients. Their tasks cal phone calls to CMOH’s triage sys- symptoms to directly reduce patient include gathering all clinical data, tem. Trained nurses utilize customized morbidity and resource utilization. n removing barriers to care by arrang- symptom management algorithms to Standardized dehydration preven- ing all necessary appointments with address clinical issues, resulting in ev- tion education and management re- specialists and primary care physi- ery clinical call being tracked, record- sulted in a dramatic decrease in the cians, and scheduling all ordered test- ed, and analyzed. Over 75% of all clin- incidence of dehydration addressed by ing to improve the timeliness of care. ical calls resulted in the management ER evaluation and hospital admissions. n The CMOH patient navigators are of symptoms at home. Approximately Longitudinal monitoring of the also instrumental in connecting pa- 10% of clinical calls resulted in an un- success of palliative care measures is tients to support services and com- scheduled office visit within 24 hours. facilitated, measured, and document- munity resources. Full EMR adop- Less than 5% of clinical calls resulted ed by software enhancements. n tion allowed CMOH to retrain in ER evaluations. Standardized management of out- administrative assistants to serve in OPCMH triage ER referrals. The patient diarrhea resulted in a decrease these enhanced patient directive roles number of incoming clinical calls re- in admissions for the treatment of within standardized guidelines being sulting in ER referral decreased by Clostridium difficile enteritis by 50%. n overseen by the physician. more than 50% over a 5-year period. A standardized approach to in- OPCMH patient engagement and The actual number of ER referrals via somnia may have resulted in reduced empowerment. For an OPCMH prac- our telephone triage service remained levels of fatigue and indirectly may tice to perform optimally, patients relatively stable over that same time, have improved performance status. must be fully engaged in their care. despite a 30% increase in patient vol- Insomnia-related symptoms are also Emphasis is placed on patient be- ume (Figure 1). utilized as a screening tool for depres- havior and a clear understanding of OPCMH unscheduled visits. As a sion. Validation of these results is cur- patient and practice responsibilities. result of expanding patient access to rently in progress. n OPCMH patient orientation empha- the CMOH clinical staff, the num- Standardized prevention of delayed sizes the following items: ber of unscheduled office visits within chemotherapy-induced nausea and n The NCQA recognition of pa- 24 hours of a clinical call more than vomiting has decreased the incidence

568 COMMUNITY ONCOLOGY ■ December 2010 www.CommunityOncology.net 14.00 6,000 tudinally as a guide to the initiation of end-of-life-care discussions and 5,606 timely hospice referrals. From 2005 12.00 5,321 5,000 11.85% 5,153 to 2009, on the day of chemotherapy 4,908 administration, roughly 90% of treat- 10.00 ed patients had an ECOG perfor- 4,359 Percentage of patients directed to ER 4,000 mance status of 0 or 1, and 8.7% had Number of active patients seen 8.00 8.58% an ECOG performance status of 2. OPCMH end-of-life care. CMOH 3,000 7.04% recently initiated an internal auditing 6.00 6.13% program to measure physician performance regarding the documenta- 5.06% 2,000 4.00 tion of end-of-life-care discussions

Total number of active patients Total with patients in a noncurative setting 1,000 (stage IV disease). CMOH measures 2.00 the documentation of end-of-life- care discussions in the physician as- Percentage of patients directed to ER via phone triage 0.00 0 sessment at the time of the initial out- 2005 2006 2007 2008 2009 patient consultation. Reassessment Year and confirmation of end-of-life-care discussions are triggered when a pa- FIGURE 1 Percentage of patients directed to an emergency room (ER) as a result of a clinical call versus the total number of active patients. tient presents with an ECOG performance status of 3. The progression of this discussion during successive 400 6,000 office visits also is monitored. End- points measured in the last 8 weeks 5,606 350 5,321 of life include ER, intensive care, and 345 5,000 5,153 hospital admissions (including length 4,908 300 of stay); chemotherapy administra-

4,359 4,000 tion; radiation therapy; and hospice 250 261 enrollment and duration. Patients seen within 24 hours of clinic call OPCMH palliative care. In patients Patient population 200 3,000 undergoing active treatment for met- 197 astatic non-small cell lung cancer, the 182 150 principles of palliative care have been 2,000 shown to improve quality of life and median survival while promoting more

Number of unscheduled visits 100 Total number of active patients Total appropriate end-of-life care.10 The 1,000 50 67 OPCMH model incorporates palliative care in conjunction with standard oncology care. CMOH physicians 0 0 2005 2006 2007 2008 2009 can longitudinally track symptoms Year and performance status in real time, at the point of care. Furthermore, all FIGURE 2 Number of patients seen within 24 hours of a clinical call versus the total number clinically active issues and symptoms of active patients. are followed in a running assessment and plan document for reference, with of delayed post-treatment nausea. It OPCMH performance status track- consideration at the time of clinical also resulted in a significant practice- ing. Performance status serves as the decision-making. wide reduction in the inappropriate focal point of patient-centered care. Adherence to clinical guidelines. use of oral 5-hydroxytryptamine 3 (5- It is the basis for decision-making Clinical guidelines, based on recom- HT3) inhibitors for delayed chemo- on the day of planned chemothera- mendations from the National Com- therapy-induced nausea (Figure 5). py administration and is used longi- prehensive Cancer Network and the

Volume 7/Number 12 December 2010 ■ COMMUNITY ONCOLOGY 569 How We Do It

3.0 PhD, the Committee Chair of the Planning Committee on Assessing and Improving Value in Cancer Care

2.5 2.600 2.567 Workshop, was recently quoted: “Un- like many areas in health care, the practice of oncology presents unique 2.0 2.067 challenges that make assessing and improving value especially complex…. A practical working description of 1.5 1.604 value in oncology would benefit many stakeholders and serve as a useful 1.273 11 1.0 1.119 model for other fields of medicine.” 0.969 As previously mentioned, the current and future challenges oncologists ER evaluations per patient year 0.5 face in their efforts to deliver effective, efficient, and appropriate care are broad and move well beyond a fo- 0 cus limited to pharmaceutical costs 2004 2005 2006 2007 2008 2009 2010 and drug utilization.11 The OPCMH Year model of cancer care can potentially serve as a practical framework to FIGURE 3 Average emergency room (ER) evaluations at Delaware County Memorial Hospital of the Drexel Hill office population per chemotherapy patient per year, 2004–2010 (YTD). more effectively address these challenges. The model has the potential to promote a value-based agenda that 500 3,500 facilitates physician accountability, 3,239 3,225 3,214 3,173 3,192 3,222 encourages clinical integration be-

435 tween like-minded medical oncology 400 3,000 groups, enhances the communication 402 406 392 and coordination of care with primary care PCMH practices, and produc- 340 300 2,500 tively collaborates with payers while 307 maintaining a focus on patient needs and evidence-based care. Enhancing physician accountability. 200 2,000 At CMOH, accountability for the

Number of admissions, July fiscal year Number of patients coordination of cancer care has been Number of admissions DCMH patient population placed on the shoulders of the medi- 100 1,500 cal oncologist. Standardization of the appropriate extension of physician oversight is a potential answer to the impending oncology physician short- 0 1,000 2005 2006 2007 2008 2009 2010 age; a shift of clinical responsibility to Fiscal year nurse practitioners or physician assistants out of necessity due to sheer vol- FIGURE 4 Number of admissions to Delaware County Memorial Hospital (DCMH) versus ume is not. the patient population in the Drexel Hill office during fiscal years 2005–2010. To promote physician accountability without creating additional bur- American Society of Clinical On- physician and practice levels. dens, the practice needed to create cology, are built into treatment care physician efficiencies. This process was Current and future plans within the oncology EMR. largely accomplished by facilitating challenges Adherence to these guidelines is an and streamlining the approach to te- essential component in the OPC- Assessing and improving value in dious data collection, time-consuming MH model and is tracked at the cancer care. Scott D. Ramsey, MD, documentation, and timely commu-

570 COMMUNITY ONCOLOGY ■ December 2010 www.CommunityOncology.net 250 for the development of care-coordination agreements between the primary care PCMH and the specialist PCMH-N.12 200 86 Encouraging payer collaboration. Refills As the cost of cancer care is rising Prescriptions at an unsustainable rate, payers and 150 government programs are looking for solutions, especially in light of prescriptions and refills 3 projected increased demands. Other 112 100 current “oncology management” so- 40 lutions available to payers are tran- sitional at best. They tend to focus

63 overwhelmingly on chemotherapy

Number of 5-HT 50 4 costs, which account for approxi- 6 33 mately 26% of the total amount 13 20 spent on cancer care. This narrowly 0 focused approach only partially ad- 2005 2007 2009 2010 vances the quality-of-care agenda Year and does not advance the value prop- osition from the patient service and FIGURE 5 Number of prescriptions and refills for oral 5-hydroxytryptamine 3 (5-HT3)- inhibi tors during the first 6 months of 2005, 2007, 2009, and 2010. disease management perspective. It has been established that ad- nication. Coddled by a well-utilized In addition, CMOH is engaged herence to chemotherapy treatment EMR, re-engineered process of care, in discussion with two large prima- pathways does result in the standard- and custom software programs, the ry care groups for potential clinical ization of drug utilization and cost OPCMH structure is capable of min- integration opportunities. The goal is reduction.14 An OPCMH practice imizing clinically irrelevant physician the development of EMR interfac- is constructed with a fully deployed activity, thereby maximizing physician es to allow data-sharing and better treatment pathways program, pro- efficiency and accountability. management in the following areas: viding more predictable chemother- Standardizing and integrating (1) initial hematology and oncology apy costs. The medical home mod- clinical care. CMOH strives for con- evaluations; (2) potentially avoidable el of cancer care, as discussed, looks tinued improvement, anticipating complications in patients with mul- beyond chemotherapy drug pathway confirmation of the value of a pa- tiple comorbid conditions; (3) estab- compliance. Practices with OPCMH tient-centric approach in the delivery lishment of the point of first triage capabilities will be positioned to be- of oncology care by expanding the during cancer therapy; (4) embed- come future providers of choice, ca- OPCMH template and infrastruc- ding of case management into the pable of transitioning to value-based ture to others. Through horizontal process of care; (5) avoidance of du- payment models.15 integration with like-minded medi- plicative laboratory and radiograph- The OPCMH is potentially trans- cal oncology practices—both aca- ic studies; (6) facilitation of end-of- formational. None of the other efforts demic and community-based—the life-care discussions; (7) transitions that payers are considering provides a practice hopes to facilitate the stan- in care from an inpatient setting; sustainable business model for com- dardization of initial assessment and (8) standardization of the referral munity oncologists. The OPCMH in- treatment algorithms. By regiment- of high-risk patients at the level of frastructure does. Focused on the es- ing data-collection points within the the primary care practice; and (9) sential demand for improved quality shared or separate EMRs, CMOH standardization of survivorship care and value, irrespective of the payment plans to track utilization in a larger plans with an agreed-upon responsi- model or the organizational structure population. Robust communication bility matrix. The American College of the parties adopting it, OPCMH and integration also allow for the of Physicians’ Council of Subspe- is flexible enough to accommodate sharing of strategies in disease man- cialty Societies recently established whatever payment changes may come agement. Extension of the OPCMH the definition of a PCMH neighbor in the future. CMOH has encouraged template to a similar-sized practice (PCMH-N), the framework for in- payers to collaborate to further refine is under way. teractions, and the guiding principles and verify this model.

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572 COMMUNITY ONCOLOGY ■ December 2010 www.CommunityOncology.net