Transcript Oncology Patient-Centered Medical Home Oncology Management Services, Inc Building the Business Case for Quality and Value John D.

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.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
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
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Joint Principles of PCMH
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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.
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 Performance
www.ncqa.org
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
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
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
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Value in Cancer Care
Evidence based care
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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
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Doing Well by Doing Good:
Improving the Business Case for Quality
Gosfield, Reinertsen, et al. 2003 *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
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
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
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Creating Value
• Care Team Work Environment 2003
• Addressing barriers to consistency and accountability
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Standardization of oncology processes
Value Proposition
Scalability
Payer Response
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Enhancing Value in Cancer Care
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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
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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
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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
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Oncology PCMH Quality & Value Driver Diagram
Triple Aim
Primary Driver
Secondary Drivers
Patient-,Payer-,and
Provider-Centered
Care Team Environment
Delivery Standards
Outcomes
Services
Process of Care Standards,
Care Integration,
Evidence Base
Multi-disciplinary
Guideline
Concordance
Engagement & Orientation
Patient & Family
Experience of Care
Palliation
Symptom Management
Focus on Performance
Status (PS)
Patient Responsibilities
Practice Responsibilities
Goals, Insurance Issues
Patient Navigation
Multidisciplinary Input
Scheduling & Tracking
Execution of Care
Avoidable Resource
Utilization
Staging/Guideline Adherence
Standardized Processes/Data
Care Coordination
Communication
ER/Hospitalizations
Imaging & Lab
Symptom Management
Survivorship Care
Standardized
Primary PCMH
End of Life Care
Hospice Enrollment
Place at Time of Death
Resource Utilization
Total Cost Of Care
Medical, Surgical, Lab
Radiation, Imaging
On Demand Access/Visits
Performance data collection
Track success of Palliation
Survivorship Care
National Committee for
Quality Assurance
PCSP Recognition
PCOC standards
American College of
Physicians PCMH-N
Patient Advocacy
NCCS, CSC, ACS
American College of
Surgeons
Commission on Cancer
Data Collection NCDB
Treatment & PC Standards
NCCN
Treatment Guidelines
Survivorship Guidelines
ASCO
QOPI Standards
Survivorship Guidelines
Standardized Care Plans
Coordination Agreements
Institute of Medicine
Goals of Therapy
National Quality Forum
National Cancer Policy Forum
Documented
PS Driven Discussions
Shared Decision Making
Payer Based Episode and
“OMH” Programs
CMS & Commercial
Data Driven Improvement
©2014 Oncology Management Services, Ltd.
Creating Value
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Care Team Work Environment
Standardization of oncology care processes
Value Proposition
Scalability
Payer Response
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
Consistent approach by the care team
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Not for redistribution.
Patient Engagement & Orientation
Patient Navigation
Shared Decision-Making
Execution of Care
Care coordination
Symptom Management
Survivorship Care
Goals of therapy
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
• Patient Engagement & Orientation
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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
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Patient Engagement & Orientation
• Patient Navigation
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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
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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
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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
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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
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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
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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
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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
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Symptom Management
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Survivorship Care
• redistribution.
Goals of therapy
Not for
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
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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
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Survivorship Care
Goals of therapy
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
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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
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Goals of therapy
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Standardization of Oncology PCMH Processes
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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
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Creating Value
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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
Outcome of Clinical Nurse Triage Phone Calls in 2013
n = 5106 clinical phone calls
Manage Symptom(s) at home
84.21%
Pt sent for
Referred to
Radiographic
Primary/Specialist
Study
5.35%
0.41%
Go to nearest ER
Office visit tomorrow
Chemo Suite Intervention 2.39%
3.47%
0.22%
Office visit today
3.96%
7.43% of patients were seen in the
office within 24 hours of call
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Average emergency room (ER) Evaluations per chemotherapy
patient per year (APCPPY)
for the CMOH patient population , 2004-2013.
3.000
ER Evaluations per chemotherapy patient per year
2.600
2.567
USON/Milliman: Approximately 2 emergency room visits per
chemotherapy patient per year
2.500
2.067
(14 million commercially insured; 104,473 cancer patients)
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
2.000
1.604
1.500
1.273
1.119
0.910
1.000
0.818
0.703
0.550
0.500
0.000
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
Year
Not for redistribution.
© 2013 Oncology Management
Services,
© 2014 Oncology
Management Services,
Consultants
in Medical&Oncology
& Hematology
Consultants in Medical
Oncology
Hematology
Average Admissions per Chemotherapy Patient Per Year (APCPPY)
for CMOH patient population, 2007-2011
1.200
1.080
USON/Milliman: Approximately 1 hospital
admission per chemotherapy patient per year (n=14
1.055
million commercially insured; 104,473 cancer patients)
1.000
Source: Milliman analysis of Medstat 2007, Milliman Health Cost Guidelines 2009
0.876
0.800
APCPPY
0.694
0.605
0.600
0.562
0.528
0.400
0.200
0.000
2007
2008
2009
2010
2011
2012
2013
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% 2007 – 2013 (CMOH)
• Practice and individual physician performance
Not for redistribution.
© 2013 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 instructions
Patient 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 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
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Oncology PCMH Survivorship Care
Care team: NP/PA + physician collaboration
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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
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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
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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.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
PCORI-NCQA-ASCO-OMS
PCORI funded Oncology Project (SEPA)
NCQA, OMS, ASCO, RAND, NCCS, IBC
PCSP Recognition
PCOC Recognition
Not for redistribution.
© 2013 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Patient-Centered Specialty Practice (PCSP)
1. Track & Coordinate Referrals
A. Referral Process and Agreements (MP)
B. Referral Content
C. Referral Response (MP)
4. Plan & Manage Care
A. Care Planning and Support Self-Care
B. Medication Management (MP)
C. Use Electronic Prescribing
2. Provide Access & Communication
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B.
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D.
Access
Electronic Access
Specialty Practice Responsibilities
Culturally and Linguistically
Appropriate Services
E. The Practice Team (MP)
3. Identify & Coordinate Patient Populations
A. Patient Information
B. Clinical Data
D. Coordinate Patient Populations
Not for redistribution.
5. Track & Coordinate Care
A. Test Tracking and Follow-Up
B. Referral Tracking and Follow-Up
C. Coordinate Care Transitions
6. Measure & Improve Performance
A. Measure Performance
B. Measure Patient/Family Experience
C. Implement and Demonstrate Continuous
Quality Improvement (MP)
D. Report Performance
E. Use Certified EHR Technology
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
Patient-Centered Oncology Care (PCOC)
1. Track & Coordinate Referrals
A. Referral Process and Agreements (L)
B. Referral Content (L)
C. Referral Response (M)
4. Plan & Manage Care
A. Care Planning and Support Self-Care (H)
B. Medication Management (H)
C. Use Electronic Prescribing (L)
2. Provide Access & Communication
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B.
C.
D.
Access (H)
Electronic Access (L)
Specialty Practice Responsibilities (M)
Culturally and Linguistically
Appropriate Services (CLAS) (L)
E. The Practice Team (H)
3. Identify & Coordinate Patient Populations
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B.
C.
D.
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Patient Information (M)
Clinical Data (L)
Comprehensive Health Assessment (H)
Coordinate Patient Populations (L)
Evidence-based Decision Support (H)
5. Track & Coordinate Care
A. Test Tracking and Follow-Up (L)
B. Referral Tracking and Follow-Up (M)
C. Coordinate Care Transitions (H)
6. Measure & Improve Performance
A. 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
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Care Team Work Environment
Process standardization
Value Proposition
Scalability
Payer Response
Not for redistribution.
© 2014 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 Consortium
CAP, CMS, CMMI, multiple payers
ASCO Payment Reform Initiatives
OMS 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
Episode or
Budgeted
FFS
Not for redistribution.
Pathways
OPCMH
Payment
model
© 2013 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
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Not for redistribution.
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
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology
CMS Oncology
Care Model (OCM)
Performance Metrics – reported quarterly
Driven by Care Team execution of PCMH processes
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Not for redistribution.
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
© 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.”
Not for redistribution.
© 2014 Oncology Management Services,
Consultants in Medical Oncology & Hematology