1. 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

2. Patient-Centered Medical Home
1967 Standards of Child Health Care
American Academy of Pediatrics
2007 Joint Principles of the PCMH
American Medical Association
American Association of Family Practitioners American Academy of Pediatrics
American College of Physicians
American Osteopathic Association

3. Joint Principles of PCMH
Personal physician coordinates comprehensive care.
Physician directed medical team.
Whole person orientation for all stages of life (acute, chronic, preventive, and end-of-life care).
Coordinated and integrated care across all aspects of the health care system utilizing information technology.
Quality and safety with continuous quality improvement and recognition by a non-governmental body.
Enhanced access through open scheduling and new communication tools.
Appropriate payment recognizing the added value with the model.

4. NCQA Primary Care Recognition
Six Standards (validated, tested elements & features)
Enhanced Access and Continuity
Identify and Manage Populations
Plan and Manage Care
Provide Self-care Support and Community Resources
Track and Coordinate Care
Measure and Improve Performance

5. Medical Neighborhood American College of Physicians
Council 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 Associate
Regulatory and Insurer Affairs

6. Quality and Cost are Completely Intertwined
“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

7. Q V= C Value in Cancer Care Evidence based care Desired outcomes
NCCN guidelines
COC program certification
ASCO QOPI certification
IOM reports Q C V=
Desired outcomes
Treatment Guideline adherence
Appropriate therapy rendered
Rational & Informed care at EOL

8. Care Team engagement essential in driving quality
Doing Well by Doing Good: Improving the Business Case for Quality Gosfield, Reinertsen, et al *2010 Update
Care Team engagement essential in driving quality
Centrality 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 jurisdiction
Drive provision of all goods and services
The Care team is the portal to the rest of the system
Referrals, 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

9. Barriers to quality = Care Team “time stealers”
Doing Well by Doing Good: Improving the Business Case for Quality Gosfield, Reinertsen, et al *2010 Update
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
Standardize
Simplify
Make clinically relevant
Engage patients
Fix accountability at the locus of control

10. Creating Value Care Team Work Environment 2003
Addressing barriers to consistency and accountability
Standardization of oncology processes
Value Proposition
Scalability
Payer Response

11. Enhancing Value in Cancer Care
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 Q C V=
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

12. 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

13. Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Patient-,Payer-,and Provider-Centered Outcomes
Primary Driver
Care Team Environment
Delivery Standards Services
Secondary Drivers Process of Care Standards, Care Integration, Evidence Base
Multi-disciplinary Guideline Concordance
Engagement & Orientation Patient Responsibilities Practice Responsibilities Goals, Insurance Issues
National Committee for Quality Assurance PCSP Recognition PCOC standards
Patient & Family Experience of Care
American College of Physicians PCMH-N
Patient Navigation Multidisciplinary Input Scheduling & Tracking
Palliation Symptom Management Focus on Performance Status (PS)
Patient Advocacy NCCS, CSC, ACS
Execution of Care Staging/Guideline Adherence Standardized Processes/Data Care Coordination Communication
American College of Surgeons
Commission on Cancer Data Collection NCDB Treatment & PC Standards
Avoidable Resource Utilization ER/Hospitalizations Imaging & Lab
NCCN Treatment Guidelines Survivorship Guidelines
Symptom Management On Demand Access/Visits Performance data collection Track success of Palliation
Survivorship Care Standardized Primary PCMH
ASCO QOPI Standards Survivorship Guidelines
Survivorship Care Standardized Care Plans Coordination Agreements
End of Life Care Hospice Enrollment Place at Time of Death Resource Utilization
Institute of Medicine National Quality Forum National Cancer Policy Forum
Goals of Therapy Documented PS Driven Discussions Shared Decision Making
Payer Based Episode and “OMH” Programs CMS & Commercial
Total Cost Of Care Medical, Surgical, Lab Radiation, Imaging
Data Driven Improvement
©2014 Oncology Management Services, Ltd.

14. Creating Value Care Team Work Environment
Standardization of oncology care processes
Value Proposition
Scalability
Payer Response

15. 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

16. 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

17. 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

18. Standardization of Oncology PCMH Processes
Standardized Engagement & Orientation
Patient Navigation
Shared Decision-Making
Explanation – specific TNM & molecular staging
Prediction – natural history, impact on performance status
Treatment options – consensus based guidelines
Financial counseling – patient OOP expenses
Patient Preferences – life goals, family responsibilities, hobbies
Plan of Care – discussed and mutually agreed upon
Goals 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

19. Standardization of Oncology PCMH Processes
Patient Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Standardized outpatient processes and work flow
Patient self assessment questionnaire (PSAQ)
Data collection and presentation drives decisions
Adherence to multidisciplinary and chemotherapy guidelines
Navigation, communication & coordination of all aspects of care
Provider team accessibility
Performance metrics monitored
Care coordination
Symptom Management
Survivorship Care
Goals of therapy

20. Standardization of Oncology PCMH Processes
Patient Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Care coordination
Multidisciplinary input – Primary, Surgery, Radiation, Medical Oncology
Timeline of intervention discussed and scheduled
Standardized communication among primary care & oncology teams
Coordination of care between oncologist, primary and other specialists
Coordination 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

21. Standardization of Oncology PCMH Processes
Patient Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Care coordination
Symptom management – during and between OP visits
Standardized symptom data collection, grading & documentation
Auto-populated fields in documentation driving physician response
Longitudinal view of success of symptom management
Documentation of specific recommendations shared with patient
Telephone triage 24/7 - standardized algorithms
Documentation of type and disposition of every call
Survivorship Care
Goals of therapy

22. Standardization of Oncology PCMH Processes
Patient Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Care coordination
Symptom Management
Survivorship Care
Consistent & 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

23. Standardization of Oncology PCMH Processes
Standardized Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Care coordination
Symptom Management
Survivorship Care
Goals of therapy
Performance Status driven decision making in non-curative setting
Standardized PS measurement
Documentation 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

24. Creating Value Care Team Work Environment Process standardization
Value Proposition – demonstration of results
Scalability
Payer Response

26. 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

27. 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

28. Multimodality Guidelines
NCCN multimodality care plans
Consensus based recommendations
Physician selects care plan within EMR
Selection shared with billing, nursing staff
NCCN Chemotherapy Guideline Compliance
Adjuvant and first line metastatic
Adherence > 95% – 2013 (CMOH)
Practice and individual physician performance

29. 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 instructions
Patient view of documentation via portal

30. Oncology PCMH End of Life Care
Performance Status Driven Decision-Making
PS: patient defined, RN/MA documentation, physicians accountable to respond
PSAQ, 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

31. 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

32. 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

33. Creating Value Care Team Work Environment Process standardization
Value Proposition
Scalability
Payer Response

34. 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

35. PCORI-NCQA-ASCO-OMS PCORI funded Oncology Project (SEPA)
NCQA, OMS, ASCO, RAND, NCCS, IBC
PCSP Recognition
PCOC Recognition

36. Patient-Centered Specialty Practice (PCSP)
Track & Coordinate Referrals
Referral Process and Agreements (MP)
Referral Content
Referral Response (MP)
Provide Access & Communication
Access
Electronic Access
Specialty Practice Responsibilities
Culturally and Linguistically Appropriate Services
The Practice Team (MP)
Identify & Coordinate Patient Populations
Patient Information
Clinical Data
D. Coordinate Patient Populations
Plan & Manage Care
Care Planning and Support Self-Care
Medication Management (MP)
Use Electronic Prescribing
5. Track & Coordinate Care
Test Tracking and Follow-Up
Referral Tracking and Follow-Up
Coordinate Care Transitions
6. Measure & Improve Performance
Measure Performance
Measure Patient/Family Experience
Implement and Demonstrate Continuous Quality Improvement (MP)
Report Performance
Use Certified EHR Technology

37. Patient-Centered Oncology Care (PCOC)
Track & Coordinate Referrals
Referral Process and Agreements (L)
Referral Content (L)
Referral Response (M)
Provide Access & Communication
Access (H)
Electronic Access (L)
Specialty Practice Responsibilities (M)
Culturally and Linguistically Appropriate Services (CLAS) (L)
The Practice Team (H)
Identify & Coordinate Patient Populations
Patient Information (M)
Clinical Data (L)
C. Comprehensive Health Assessment (H)
D. Coordinate Patient Populations (L)
E. Evidence-based Decision Support (H)
Plan & Manage Care
Care Planning and Support Self-Care (H)
Medication Management (H)
Use Electronic Prescribing (L)
5. Track & Coordinate Care
Test Tracking and Follow-Up (L)
Referral Tracking and Follow-Up (M)
Coordinate Care Transitions (H)
Measure & Improve Performance
Measure Performance (L)
Measure Patient/Family Experience (L)
Implement and Demonstrate Continuous Quality Improvement (M)
Report Performance (L)
Use Certified EHR Technology (L)
Element Priority: Low (L); Medium (M); High (H)

38. Creating Value Care Team Work Environment Process standardization
Value Proposition
Scalability
Payer Response

39. 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 Consortium CAP, CMS, CMMI, multiple payers ASCO Payment Reform Initiatives OMS CMOH Alternate Payment Methods in SEPA IBC, Keystone First, (48% of patients)

40. Provider Ability & Accountability Payment Reform for cancer care
Episode or Budgeted
Payment model
FFS
Pathways
OPCMH

41. 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

42. CMS Oncology Care Model (OCM)
Performance Metrics – reported quarterly
Driven 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

43. 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.”