At the heart of the Oncology Medical Home is triage, according to Barbara L. McAneny, MD, a board certified medical oncologist at New Mexico Oncology Hematology Consultants, and founder of Innovative Oncology Business Solutions (IOBS).
In 2012, Dr McAneny and IOBS were awarded a $19.8-million grant from the Center for Medicare & Medicaid Innovation at the Centers for Medicare & Medicaid Services (CMS) to test how private oncology practices could provide better care to cancer patients at a lower cost. The resulting model, called COME HOME (Community Oncology Medical Home), was implemented in 7 practices around the country, and later helped form Medicare’s Oncology Care Model.
“The COME HOME vision is all centered around triage,” she said at the Academy of Oncology Nurse & Patient Navigators 7th Annual Navigation & Survivorship Conference. “We try to make sure that when patients call in they reach someone who knows something about their disease, the drugs they’re taking and the side effects, and also about them as a person, so that they can get the care they need.”
“I’ve got to use cancer drugs, and frankly, Pharma doesn’t care if I think they’re priced too high,” she added. “But I thought we could make a difference in aggressively managing the side effects and complications of cancer and its treatment. And that’s what we set out to do.”
The COME HOME Model
IOBS created the COME HOME triage system to provide aggressive, standardized symptom management for patients, thereby reducing ED utilization and inpatient admissions and costs. Dr McAneny said the model redefines quality by incorporating the technical goal of delivering the right care, with the customer service goal of respecting the time, wishes, and goals of the patient.
“One of the things I’ve learned in years of being an oncologist is that every time I put a patient in the hospital, they come out with a little less quality of life,” Dr McAneny stated. “So I started this project not because of a desire to save insurance companies money but because my patients are going bankrupt, and they don’t have extra money to spend on healthcare.”
She said the healthcare model in the United States is not sustainable, and the consolidation of physician practices into hospitals is costing the country a lot of money it doesn’t have. “We’ve lost about 1300 clinics over the last 6 years, and we’re on track to spend 17% of GDP on healthcare,” she reported. The United States has the most expensive healthcare system in the world but ranks 19th among the industrialized nations in preventing illnesses that are amenable to medical intervention, and cancer is a big part of the problem. The cost of cancer drugs often takes the spotlight due to the dramatic rise in the cost of these pharmaceuticals, but the cost of cancer medical care is not far behind. She said she can’t control the cost of cancer drugs, “but what I can control is how often and how long I put people in the hospital, and how I manage their symptoms.”
COME HOME clinics deliver all outpatient cancer care, and their triage system ensures that patients receive the right care, in the right place, at the right time, by helping them to manage the side effects of their cancer and its treatment at the most cost-effective site and at the earliest stage of development.
The Triage System
Participation in the COME HOME model requires a robust use of health IT systems (EMR, PMS, lab systems, etc) so that data can be used to measure the success of the program. It mandates an ongoing relationship with a personal oncologist to provide first contact and continuous comprehensive care to patients. “When people are sick, they want to know who their doctor is,” she said. It utilizes a physician-led, team-based care model where every member of the team works at the top of his or her license and incorporates patient and family education.
“Patients don’t call up and say, ‘I have squamous cell carcinoma of the tonsil,’ they call and say ‘my throat hurts,’” said Dr McAneny. So when a patient calls in, a first responder focuses on 1 of 38 symptom-specific pathways, (eg, pain, nausea and vomiting, fatigue), utilizing a real-time, decision support web-based system that is already populated with patient demographic data. Then, if the caller is not experiencing a true medical emergency necessitating immediate admission to a hospital, the first responder places the patient-related calls on a dashboard for the triage nurses. The triage nurses take the calls from the dashboard and begin the triage assessment.
Phones are answered by the fourth ring, and calls are returned within 2 hours for routine complaints. She said about one-third of patients get a same-day appointment, and only about 1% of people require a call to 911.
Standard order sets are already outlined in the system for defined patient groups (eg, patients on chemotherapy with fever are scheduled for same-day appointments and have chemistry and CBC ordered without needing physician sign-off). “The triage nurses are the center of this universe,” she said. “We have schedules that have blanks, and the nurses have the power to fill them. They don’t have to ask permission or forgiveness.”
The triage pathways guide the triage nurses by providing better patient management, improving timeliness and coordination of care, ensuring safe and seamless care, and enhancing patient care experiences, she said. A second dashboard is used to follow up on patients and is only used by the triage nurses.
Because of same-day visits and fewer ED and inpatient visits, estimated savings to Medicare over the 2-year grant period is $1.6 million per month, or approximately $175,000 per practice, per month. Of the 1223 same-day visits seen per month due to the model, 245 (20%) would have gone to the ED, and of those, 152 (62.3%) would have been admitted.
“We’ve really cut down on patient admissions, which patients love,” said Dr McAneny. “Hospitals don’t like this, but I’m not bothered by that.”
She said now that the CMS grant is over, they’ve been working with the American Society of Clinical Oncology model, Patient-Centered Oncology Payment, which offers 3 options for transition away from fee-for-service, all of which provide accountability for things oncologists can control. IOBS, the company Dr McAneny created to manage the award, is now assisting physician practices in developing the process changes needed for the Medicare Access and CHIP Reauthorization Act.
“We have to get the patients what they need, when they need it, and we have to have a system behind it to make sure we can do this properly,” Dr McAneny added. “And when we do that, we can have fewer days in the hospital, which is of value to my patients primarily, and is of huge value to whoever is paying the bills.”
The Austin Cancer Center Experience
Austin Cancer Center was one of the 7 practices in which the COME HOME model was implemented. According to Gina Kuenstler, BSN, RN, OCN, Oncology Nurse Navigator and Navigation Program Manager at Austin Cancer Center, implementation of the program resulted in increased patient satisfaction, improved documentation, a streamlined phone triage, and better chemotherapy education.
“Because of COME HOME, we saw better care coordination and decreased time to treatment,” she reported. “Administration and key physician partners began to open up to the program and to the value of navigation, and as a result they significantly expanded their support of navigation at Austin Cancer Center,” she said.
Their practice was able to establish consistent documentation guidelines, which improved communication and care collaboration. They also ensured more efficient and timely scheduling for patients by making policy changes that opened physicians’ schedules to same-day appointments, and increased their number of first responders (operators), so telephones could be answered quickly and patients could be triaged to the appropriate staff.
She said one of the biggest challenges to implementing the program was helping patients understand and trust a change in the way they access the healthcare system, especially for side effect management. “We explain to them they don’t have to run to the ER; we have on-call physicians and after-hour and weekend clinics, and they should utilize those,” she said, adding that there was a desperate need for ongoing staff education to help them understand the benefit of the extended clinics and why patients should be referred there for symptom management.
She said she initially struggled to garner interest in distress screening and survivorship care plans, but due to COME HOME, Austin Cancer Center has begun the process of distress screening through a patient services director, and a nurse practitioner–led team is taking on survivorship care planning.
“I truly feel it takes a village, and administrative support, physician champions, patient advocates, patient-education resources, transparent communication, and of course, navigation, are nonnegotiable essentials to the success of the COME HOME project,” said Ms Kuenstler.
“Hearing what Austin has been able to do makes me feel like a proud mother for creating this,” Dr McAneny commented.