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Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Patient-Centered Medical Home
Oncology Management Services, Inc
Building the Business Case for
Quality and Value
John D. Sprandio, MD, FACP
October 3, 2014
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Patient-Centered Medical Home
1967 Standards of Child Health CareAmerican Academy of Pediatrics
2007 Joint Principles of the PCMH American Medical AssociationAmerican Association of Family Practitioners American Academy of PediatricsAmerican College of PhysiciansAmerican Osteopathic Association
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Joint Principles of PCMH
1. Personal physician coordinates comprehensive care.
2. Physician directed medical team.
3. Whole person orientation for all stages of life (acute, chronic, preventive, and end-of-life care).
4. Coordinated and integrated care across all aspects of the health care system utilizing information technology.
5. Quality and safety with continuous quality improvement and recognition by a non-governmental body.
6. Enhanced access through open scheduling and new communication tools.
7. Appropriate payment recognizing the added value with the model.
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
NCQA Primary Care Recognition
Six Standards (validated, tested elements & features)
1. Enhanced Access and Continuity
2. Identify and Manage Populations
3. Plan and Manage Care
4. Provide Self-care Support and Community Resources
5. Track and Coordinate Care
6. Measure and Improve Performancewww.ncqa.org
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Medical Neighborhood
American College of PhysiciansCouncil of Subspecialty Societies (CSS), Policy Paper 2010 Addressed relationship between primary care PCMH model and
specialty/subspecialty practices Highlights:
Established definition of Patient Centered Medical Home Neighbor Approved a framework to categorize interactions between PCMH and PCMH - N Approved guiding principles of the development of care-coordination agreements
between PCMH and PCMH-N
Neil Kirschner, Ph.D.American College of Physicians, Senior AssociateRegulatory and Insurer Affairs
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Quality and Cost are Completely Intertwined
Quality: “The degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (IOM 1997)
Cost: Resource utilization related to delivery of care
Value:“The degree to which health services increase the likelihood of desired health outcomes, are consistent with current professional knowledge AND are delivered with the proper allocation of resources”
The utilization of unnecessary resources IS poor quality of care
Value in Cancer Care
7
V= QC
Evidence based care• NCCN guidelines• COC program certification • ASCO QOPI certification• IOM reports 1997-2013
Desired outcomes• Treatment Guideline adherence• Appropriate therapy rendered• Rational & Informed care at EOL
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Doing Well by Doing Good:Improving the Business Case for Quality
Gosfield, Reinertsen, et al. 2003 *2010 Update
Care Team engagement essential in driving qualityCentrality of the care team-patient relationship:• Clinical team provides 1-on-1 interaction that defines healthcare
Explanation, prediction, plan of care• Physicians and advanced practitioners have the broadest scope of
professional jurisdictionDrive provision of all goods and services
• The Care team is the portal to the rest of the systemReferrals, education, interpretation of insurance benefits
• Care Team members face barriers on their way to becoming accountable for the quality and consistency of care they deliver
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Barriers to quality = Care Team “time stealers”EMR, work-flow, niche competitors, documentation & communication hurdles. Variable: data collection, data presentation, decision support, outcome measures.
Absence of real-time performance measurement, efficiency tools, and payer support.
Care Team work environment redesign StandardizeSimplifyMake clinically relevantEngage patientsFix accountability at the locus of control
Doing Well by Doing Good:Improving the Business Case for Quality
Gosfield, Reinertsen, et al. 2003 *2010 Update
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment 2003• Addressing barriers to consistency and accountability
• Standardization of oncology processes• Value Proposition• Scalability• Payer Response
Enhancing Value in Cancer Care
11
V= QC
Addressing Care Team Barriers• Streamline processes• Standardize roles & responsibilities• Minimize clinically irrelevant activity • Improve patient/family engagement• Fix accountability at locus of control• Data systems tracking performance • Continuously improve performance
• Treatment Guideline adherence• Appropriate therapy rendered• Rational & Informed care at EOL• Enhanced patient access• Improved patient navigation,
coordination & communication• Reduced avoidable complications• Reduced unnecessary utilization
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology Patient-Centered Medical Home®
• NCQA level III, PCMH recognition April 2010• Integrated care delivery model for hematology & oncology• PCMH principles: access, engagement, shared decisions,
coordination, communication and accountability• Medical oncology serves as the hub of coordination and
accountability in meeting cancer care needs • Integrates Primary PCMH, surgical, radiation oncology,
inpatient, social, hospice services via information hub• Value Proposition: Better cancer care, health, lower cost• Payer recognition, integration with ACOs, Clinically Integrated
Networks
Oncology PCMH Quality & Value Driver DiagramOncology PCMH Quality & Value Driver Diagram
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Triple AimPatient-,Payer-,and Provider-Centered
Outcomes
Primary Driver Care Team Environment Delivery Standards
Services
Primary Driver Care Team Environment Delivery Standards
Services
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
Secondary Drivers Process of Care Standards,
Care Integration, Evidence Base
National Committee for Quality Assurance
PCSP Recognition PCOC standards
National Committee for Quality Assurance
PCSP Recognition PCOC standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards
American College of Surgeons
Commission on Cancer Data Collection NCDB
Treatment & PC Standards NCCN
Treatment Guidelines Survivorship Guidelines
NCCN Treatment Guidelines
Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
ASCO QOPI Standards Survivorship Guidelines
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Institute of Medicine National Quality Forum
National Cancer Policy Forum
Patient Advocacy NCCS, CSC, ACS
Patient Advocacy NCCS, CSC, ACS
American College of Physicians PCMH-NAmerican College of Physicians PCMH-N
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Engagement & Orientation Patient Responsibilities
Practice Responsibilities Goals, Insurance Issues
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Execution of Care Staging/Guideline Adherence Standardized Processes/Data
Care Coordination Communication
Symptom Management
On Demand Access/Visits Performance data collection Track success of Palliation
Symptom Management On Demand Access/Visits
Performance data collection Track success of Palliation
Survivorship Care Standardized Care Plans
Coordination Agreements
Survivorship Care Standardized Care Plans
Coordination Agreements
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Goals of Therapy Documented PS Driven Discussions
Shared Decision Making
Data Driven ImprovementData Driven Improvement
Multi-disciplinary Guideline
Concordance
Multi-disciplinary Guideline
Concordance
Palliation Symptom Management Focus on Performance
Status (PS)
Palliation Symptom Management Focus on Performance
Status (PS)
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Avoidable Resource Utilization
ER/Hospitalizations Imaging & Lab
Patient & Family Experience of Care
Patient & Family Experience of Care
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
End of Life Care Hospice Enrollment
Place at Time of Death Resource Utilization
Survivorship Care Standardized
Primary PCMH
Survivorship Care Standardized
Primary PCMH
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging
Total Cost Of Care Medical, Surgical, Lab
Radiation, Imaging ©2014 Oncology Management Services, Ltd.
Payer Based Episode and “OMH” Programs
CMS & Commercial
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment• Standardization of oncology care processes • Value Proposition• Scalability• Payer Response
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
Consistent approach by the care team• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Define role of nurse and patient navigators, physicians, etc• Modes of enhanced access & coordination defined• Financial counseling – details of insurance coverage • Patient reporting & practice responsibilities• Practice as “Point of First Triage” • Symptom and disease management strategies (nurse triage)• Patient Portal education
• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation
• Patient Navigation• Lay Navigators• Scheduling of all imaging, laboratory testing • Precertification of necessary imaging• Scheduling all external provider appointments
Oncologic and non-oncologic
• Tracking test results and consultation reports to completion Re-scheduling when necessary
• Interface/scanning of reports • Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Standardized Engagement & Orientation• Patient Navigation
• Shared Decision-MakingExplanation – specific TNM & molecular stagingPrediction – natural history, impact on performance status Treatment options – consensus based guidelinesFinancial counseling – patient OOP expensesPatient Preferences – life goals, family responsibilities, hobbies Plan of Care – discussed and mutually agreed uponGoals of therapy defined – curative or palliative Written or electronic plan shared with patient/stakeholders
• Execution of Care• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making
• Execution of CareStandardized outpatient processes and work flowPatient self assessment questionnaire (PSAQ)Data collection and presentation drives decisionsAdherence to multidisciplinary and chemotherapy guidelinesNavigation, communication & coordination of all aspects of careProvider team accessibilityPerformance metrics monitored
• Care coordination • Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care
• Care coordinationMultidisciplinary input – Primary, Surgery, Radiation, Medical OncologyTimeline of intervention discussed and scheduledStandardized communication among primary care & oncology teamsCoordination of care between oncologist, primary and other specialistsCoordination of care arrangements define responsibilities (PCMH-N)Transitions of care OP to ER or Admission, admission to OP
• Symptom Management• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination
• Symptom management – during and between OP visitsStandardized symptom data collection, grading & documentationAuto-populated fields in documentation driving physician
response Longitudinal view of success of symptom managementDocumentation of specific recommendations shared with patientTelephone triage 24/7 - standardized algorithms Documentation of type and disposition of every call
• Survivorship Care• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management
• Survivorship CareConsistent & Coordinated Care Plans
• Progress note templates integrated into software overlay“Assessment & Survivorship Care Plan”
• Coordination agreements with primary care team (ACP PCMH-N)• Dissemination of information to all involved providers• Enhanced patient interaction with community support services
• Goals of therapy
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Standardized Engagement & Orientation• Patient Navigation• Shared Decision-Making• Execution of Care• Care coordination • Symptom Management• Survivorship Care
• Goals of therapyPerformance Status driven decision making in non-curative setting
Standardized PS measurementDocumentation of ongoing goals dialogue based on PS changes
Goals of therapy updated via replay of: Explanation, Prediction, Options, Patient Preference, Plan of
Care Hospice utilization monitored
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment• Process standardization • Value Proposition – demonstration of results• Scalability• Payer Response
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Go to nearest ER2.39%
Chemo Suite Intervention0.22%
Office visit today3.96%
Office visit tomorrow3.47%
Referred to Pri-mary/
Special-ist
5.35%
Pt sent for Ra-
dio-graphic Study0.41%
Manage Symptom(s) at home84.21%
Outcome of Clinical Nurse Triage Phone Calls in 2013n = 5106 clinical phone calls
7.43% of patients were seen in the of-fice within 24 hours of call
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
2.600 2.567
2.067
1.604
1.273
1.119
0.9100.818
0.703
0.550
0.000
0.500
1.000
1.500
2.000
2.500
3.000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Year
Average emergency room (ER) Evaluations per chemotherapy patient per year (APCPPY)
for the CMOH patient population , 2004-2013.
ER
Eva
lua
tio
ns p
er
ch
em
oth
era
py p
ati
en
t p
er
ye
ar
USON/Milliman: Approximately 2 emergency room visits per chemotherapy patient per year
(14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
© 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
2007 2008 2009 2010 2011 2012 20130.000
0.200
0.400
0.600
0.800
1.000
1.200
1.0801.055
0.876
0.605
0.528
0.694
0.562
Average Admissions per Chemotherapy Patient Per Year (APCPPY) for CMOH patient population, 2007-2011
APCP
PY
USON/Milliman: Approximately 1 hospital admission per chemotherapy patient per year (n=14 million commercially insured; 104,473 cancer patients)Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Multimodality Guidelines
NCCN multimodality care plansConsensus based recommendations Physician selects care plan within EMR
• Selection shared with billing, nursing staff
NCCN Chemotherapy Guideline ComplianceAdjuvant and first line metastatic
• Adherence > 95% 2007 – 2013 (CMOH)• Practice and individual physician performance
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology PCMH Palliative Care
Concurrent delivery of palliative care• Comprehensive health assessment each visit• Symptoms: patient defined, RN/MA confirmed, physician
accountable to respond • NCI graded and longitudinally viewed• Dynamic problem list of symptoms, co-morbid conditions
Documentation of ongoing management Use of standardized approaches and instructionsPatient view of documentation via portal
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology PCMH End of Life Care
Performance Status Driven Decision-Making• PS: patient defined, RN/MA documentation, physicians
accountable to respondPSAQ, ECOG grading (fixed), physician prompt
• PS longitudinally viewed by patient and physician• Physician accountability
Systems that monitor for changes in PS (ECOG 3) Documentation of rationale for continuation of
therapy Transparency of discussion of goals Patient visibility of documentation via portal
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology PCMH Survivorship Care
Care team: NP/PA + physician collaboration • Survivorship care plan templates (ASCO)• Clinical summary (toxicities, co-morbidities)• Documentation of management of residual symptoms• Treatment summary, genetic testing, family history• Surveillance and screening activities, immunizations • Community resource utilization• Coordination of care arrangements in survivorship
Responsibility matrix defined
Primary PCMH, Oncology PCMH, Radiation and Surgical teams •
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Oncology PCMH Transitions of Care
Transition responsibility: facilitating hand-offs• Symptomatic patients with an apparent new malignancy from
ER, Primary PCMH or specialist office • Oncology team drives efficiency, shortening timeline to diagnosis,
symptom control and treatment• Symptom control = reduced unnecessary ER visits, admission
• From oncology office to ER or inpatient admission• Transfer of information to accepting parties• Notification to Primary PCMH team
• From acute care to outpatient or skilled care• Scheduling of all testing, consultation and follow-up visits• Notification to Primary PCMH team
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment• Process standardization • Value Proposition• Scalability• Payer Response
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Scalability of Model
Address care team barriers (Readiness Assessment)• Process and technology framework: merging work-flow,
data collection/presentation, documentation, communication
Standards, elements and features of care processes• Oncology specific (NCQA, COC, TJC)
Internal feedback of relevant practice performance data Knowledge driven continuous improvement
Payer Response • Alternate Payment Methods
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
PCORI-NCQA-ASCO-OMS
PCORI funded Oncology Project (SEPA)
NCQA, OMS, ASCO, RAND, NCCS, IBC
PCSP RecognitionPCOC Recognition
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Patient-Centered Specialty Practice (PCSP)
1. Track & Coordinate ReferralsA. Referral Process and Agreements (MP) B. Referral Content C. Referral Response (MP)
2. Provide Access & CommunicationA. AccessB. Electronic Access C. Specialty Practice Responsibilities D. Culturally and Linguistically
Appropriate Services E. The Practice Team (MP)
3. Identify & Coordinate Patient PopulationsA. Patient InformationB. Clinical Data D. Coordinate Patient Populations
4. Plan & Manage CareA. Care Planning and Support Self-Care B. Medication Management (MP)C. Use Electronic Prescribing
5. Track & Coordinate Care
D. Test Tracking and Follow-UpE. Referral Tracking and Follow-Up F. Coordinate Care Transitions
6. Measure & Improve PerformanceG. Measure Performance H. Measure Patient/Family Experience I. Implement and Demonstrate Continuous
Quality Improvement (MP)J. Report Performance K. Use Certified EHR Technology
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Patient-Centered Oncology Care (PCOC)
1. Track & Coordinate ReferralsA. Referral Process and Agreements (L)B. Referral Content (L)C. Referral Response (M)
2. Provide Access & CommunicationA. Access (H)B. Electronic Access (L)C. Specialty Practice Responsibilities (M)D. Culturally and Linguistically
Appropriate Services (CLAS) (L)E. The Practice Team (H)
3. Identify & Coordinate Patient PopulationsA. Patient Information (M)B. Clinical Data (L)C. Comprehensive Health Assessment (H) D. Coordinate Patient Populations (L)E. Evidence-based Decision Support (H)
4. Plan & Manage CareA. Care Planning and Support Self-Care (H)B. Medication Management (H)C. Use Electronic Prescribing (L)
5. Track & Coordinate Care
D. Test Tracking and Follow-Up (L)E. Referral Tracking and Follow-Up (M) F. Coordinate Care Transitions (H)
6. Measure & Improve PerformanceA. Measure Performance (L)B. Measure Patient/Family Experience (L)C. Implement and Demonstrate Continuous
Quality Improvement (M)D. Report Performance (L)E. Use Certified EHR Technology (L)
Element Priority: Low (L); Medium (M); High (H)
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment• Process standardization • Value Proposition• Scalability• Payer Response
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Payment Reform
PCORI funded Oncology Project (SEPA)NCQA, OMS, ASCO, RAND, NCCS, IBC
CMS Oncology Payment Reform TEP MITRE, Brookings, RAND, CMS, CMMI
Oncology Bundled Payment ConsortiumCAP, CMS, CMMI, multiple payers
ASCO Payment Reform InitiativesOMS CMOH Alternate Payment Methods in SEPA
IBC, Keystone First, (48% of patients)
Not for redistribution. © 2013 Oncology Management Services,Consultants in Medical Oncology & Hematology
Provider Ability & Accountability Payment Reform for cancer care
FFS Pathways OPCMH
Episode or Budgeted
Payment model
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
CMS Oncology Care Model (OCM)
Combined features of CMS Oncology Payment Reform TEP + CAP Bundled Payment Consortium
Medical oncology treatment episodes - broadly applied PCMH Practice Transformation
• Patient Navigators• Enhanced Coordination• Structured Care Plan (IOM)• 24/7 access to clinician with records• Adherence to nationally recognized treatment guidelines• Oncology specific EHR, stage 2 MU by end of year three• Data driven quality improvement program
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
CMS Oncology Care Model (OCM)
Performance Metrics – reported quarterlyDriven by Care Team execution of PCMH processes
• ER visits/Hospital admissions (episode + 6 months & EOL)• CAHPS (oncology version)• Comprehensive health assessment, including PS • Psychological screening (once/episode)• Palliative care (concurrently or via formal consultation)• Transition coordination and follow-up testing/OP visits• Medication reconciliation • Pain management• Hospice Utilization• Resource Utilization (Drugs, radiation therapy, imaging, laboratory)• Results of data driven quality improvement efforts
Not for redistribution. © 2014 Oncology Management Services,Consultants in Medical Oncology & Hematology
Principles of PCMH-N Applied to Cancer Care
PCMH standards + supportive technology applied to primary and specialty care enables a neighborhood of practices that deliver what Don Berwick called for in 2012:
“…. an electronic line-of-sight contact with each other all day long, weaving a net of help and partnership with patients and families.”