Not for redistribution. © 2013 Oncology Management Services, Consultants in Medical Oncology &...

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


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


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.


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

http://www.ncqa.org/


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


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


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


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


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


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


Creating Value

• Care Team Work Environment• Standardization of oncology care processes • Value Proposition• Scalability• Payer Response


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



• 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



• 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



• 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



• 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



• 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



• 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



• 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



• 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


Creating Value

• Care Team Work Environment• Process standardization • Value Proposition – demonstration of results• Scalability• Payer Response


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


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


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


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


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


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 •


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


Creating Value

• Care Team Work Environment• Process standardization • Value Proposition• Scalability• Payer Response


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


PCORI-NCQA-ASCO-OMS

PCORI funded Oncology Project (SEPA)

NCQA, OMS, ASCO, RAND, NCCS, IBC

PCSP RecognitionPCOC Recognition


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


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)


Creating Value

• Care Team Work Environment• Process standardization • Value Proposition• Scalability• Payer Response


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)


Provider Ability & Accountability Payment Reform for cancer care

FFS Pathways OPCMH

Episode or Budgeted

Payment model


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


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


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.”

Not for redistribution. © 2013 Oncology Management Services, Consultants in Medical Oncology &...

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