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High-Impact Workflow Changes for Value-Based Care Success

Charles Saunders, MD; Charles Alcorn, MS; Catherine Cowan, MSN, RN; and Maria Fabbiano
As oncology practices transition to value-based care, they are challenged to take on more holistic responsibility for their patient. Fortunately, the examples of practices participating in CMS’ Oncology Care Model can offer valuable insight into the most impactful workflow changes providers can implement as they strive to achieve cost and quality improvements.
As a result, a pattern of access behavior was established that shuttled the patient to the acute care environment and resulted in admission regardless of patient needs or acuity. Unfortunately, although financial incentives further encourage acute care admission in many US markets, practices also bear responsibility by providing contradictory messaging and few options to patients. For example, patient messaging is ubiquitous and includes the instruction “if you have a medical emergency, hang up and call 911.” What often remains unappreciated is that for oncology patients, every acute complaint is interpreted as an emergency. Thus, practices are undertaking multiple activities to shape acute care utilization for nonemergent care. These conditions frequently include constipation, urinary tract infection, fatigue, malaise, weakness, anemia, respiratory infections, dehydration, nausea, and vomiting. These conditions are highly amenable to ambulatory care interventions and generally do not require acute care services.

To redirect patients to the correct site of care, one group of OCM practices conducted organized audits of their messaging for clarity and consistency to deduce appropriate next steps for patients with acute complaints. This entailed a methodical examination of all patient-facing materials and talk tracks, including brochures, answering service messaging, on-hold messaging, handouts, websites, and any other promotional materials. Post audit, all 911 messaging was revised by:
  • Defining “emergency” in all patient materials
  • Removing prior 911 messaging and having the patient contact the oncology practice before access to acute care
  • Diminishing the placement of the messaging, as appropriate
Other productive interventions included efforts to actively direct the patient to the appropriate level of care. Administrators established practice orientation classes as part of the new patient process, with handouts detailing how to handle emergencies and stressing that patients contact their oncologist before proceeding to acute care, along with outlining the dangers of unnecessary acute care utilization, including ED exposure to pathogens, especially for the neutropenic patient. Many practices have also provided patient wrist bands with the practice phone number to remind patients to call them first. Finally, practices have re-engineered their own patient-facing workflows through the adoption of purpose-built symptom management protocols, such as those developed for the COME HOME program and subsequently expanded by Innovative Oncology Business Solutions—resulting in documented improvements in cost of care.

Other important interventions include:
  • Expanding office hours to make it easier for patients to be seen faster and per their convenience
  • Establishing relationships with local urgent care facilities to appropriately direct incoming patients
  • Standardizing ED protocols with local hospital partners to better recognize and respond to the needs of the practice’s patients
  • Aiming highly targeted case management at so-called frequent flyers who repeatedly visit the ED with their acute complaints
  • Hosting chemotherapy-specific education programs so patients can better understand and address specific symptoms as they emerge during treatment
  • Providing Web and mobile tools that provide 24/7 information and access to appropriate clinical insight
Deploy End-of-Life and Supportive Care Programs

Oncology practices have traditionally struggled when it comes to care delivered in the last weeks of life. While on one hand supportive care does not extend to enough people, the rising costs of healthcare have also transferred a substantial burden to patients, families, and the healthcare system at the end of life. Poor comprehension of the reality of care options, especially when further efforts are fruitless, prolongs suffering, discomfort, and distress for patients and families while incurring substantial cost without the hope for a positive outcome. However, the momentum behind value-based care models is compelling practices to review care management at the end of life and incorporate new approaches.

An emerging group of OCM practices are taking the stance that families deserve a full exploration of care options at the end of life in concert with some payers going so far as to promote full disclosure. Unfortunately, with the ongoing proliferation of the internet, patients and families sometimes interpret advertising as an appropriate source of clinical data and pressure oncologists to provide such care nonetheless. However, study results indicate that care provided under these circumstances is not only not helpful to patients and families, but can harm them. A study published July 23, 2015 in JAMA Oncology,4 found that among the patients who were generally healthy and active at the start of the study, palliative chemotherapy use was associated with worse quality of life in their last week of life and showed no benefit to overall survival. Those who were less healthy at the study’s outset experienced no net effect from the treatment, both in quality of life and survival.

What are leading practices doing to address these complex challenges? They are taking approaches that include:
  1. Instituting aggressive advance care programs early in the disease trajectory, leveraging counselors
  2. Introducing palliative and supportive care programs that can evolve into end-of-life activities as needed
  3. Leveraging their care management and navigation capabilities to see appropriate patients through the final stages of their disease. These approaches have been validated by results from similar efforts established among payers, such as Aetna’s Compassionate Care Program.3
Conclusion

Value-based care is a vision for advancing the Triple Aim that has united stakeholders across the healthcare spectrum, without an equally aligned road map for fulfilling its promise. However, a core group of OCM practices has begun to forge a path with our company, Integra Connect, that places a laser focus on the top cost drivers; directly targets those drivers with focused, high-impact interventions; and ingrains those interventions into the core daily workflows of the practice as well as the composition and focus of care teams. To optimize efficiency, they enable those work flows with new technologies that aggregate disparate sources of data into a holistic patient view that supports their transition to whole person care while simultaneously realizing cost and quality targets for ongoing financial and clinical success.

Source of Funding: Integra Connect.

Author Information: Charles Saunders, MD, is the chief executive officer at Integra Connect.
 Charles Alcorn, MS, is the senior director of medical economics at Integra Connect.
 Catherine Cowan, MSN, RN, is the vice president of population health and practice transformation at Integra Connect.
 Maria Fabbiano, RN, is the vice president of clinical program development at Integra Connect.

Address Correspondence toCharles Saunders, MD, Integra Connect, 
501 S Flagler Dr, Suite 600, West Palm Beach, FL 33401. E-mail: charles.saunders@integraconnect.com.
REFERENCES
1. MIPS scoring methodology overview. CMS website. cms.gov/Medicare/Quality-Initiatives-Pa- tient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MIPS-Scoring-Methodology-slide-deck.pdf. Accessed October 6, 2017.

2. Oncology Care Model. CMS website. innovation.cms.gov/initiatives/oncology-care. Updated October 5, 2017. Accessed October 6, 2017.

3. Wade M. A comprehensive case management program to improve access to palliative care: Aetna’s Compassionate Care. Global Health Care website. ehcca.com/presentations/palliativesummit1/wade_ms3.pdf. Accessed October 6, 2017.

3. Prigerson HG, Bao Y, Shah MA, et al. Chemotherapy use, performance status, and quality of life at the end of life. JAMA Oncol. 2015;1(6):778-784. doi: 10.1001/jamaoncol.2015.2378.
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