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Implementing Practice Transformation, Integrating Primary Care to Provide High-Quality Cancer Care

Jaime Rosenberg
As practices work to provide the best care for their patients while also containing costs, it has become clear that the old ways of doing things won’t cut it.
As practices work to provide the best care for their patients while also containing costs, it has become clear that the old ways of doing things won’t cut it. As a result, practice transformation has become a norm for many practices looking to succeed under value-based care models, such as the Oncology Care Model (OCM).

For Jefferson Health, the process began a decade ago as the health system decided to develop a multidisciplinary geriatric oncology evaluation center, explained Andrew E. Chapman, DO, FACP, chief of cancer services at Sidney Kimmel Cancer Center, during the second half of The American Journal of Managed Care®’s Institute for Value-Based Medicine® (IVBM) session held September 19, 2019, in Philadelphia, Pennsylvania.

The center implemented a team-based model, bringing together social work, pharmacy, nutrition, and medical oncology. What it learned, explained Chapman, was that the group of patients—aged 65 years and older and account for the majority of cancer diagnoses, deaths, and survivors—are a significantly vulnerable population due to confounding factors, such as comorbidities and polypharmacy.

This, coupled with a fragmented healthcare system, caused Jefferson Health to step back and ask, “How can we think about how to address these cracks and think about this patient population in this fragmented system, and can we do something better?”

From there, the health system started down the path of practice transformation. This process was heightened as the National Committee for Quality Assurance introduced its Patient-Centered Medical Home Model and even more so with CMS’ introduction of the OCM.

Thinking about what needed to be addressed throughout the process, Jefferson Health came away with multiple aspects of care it wanted to implement, including team-based care, patient care management, and care coordination.

From there, Jefferson Health worked on building the infrastructure of a system that could withstand the changes needed, facilitating engagement with providers by creating a culture in which they understood how interrelated they are to the healthcare delivery system, and offering assessment to the providers by providing them data and feedback.

“The oncology care model for us has been this test tube for us to try and test really different opportunities in terms of building this infrastructure, sharing these data analytics, and trying to really evolve as a practice,” said Chapman.

 Flash forward to 2019, and Jefferson Health has laid out a series of goals it wants to act on:
  • Develop and execute a strategy for addressing care needs across the continuum of care through navigation and supportive medicine
  • Execute a strategy to reduce cost and care variation
  • Demonstrate improvement in guiding patient to the appropriate site of care and creating meaningful care goals
  • Disseminate this data through a community strategy so that providers understand what is being measured and why it’s important
  • Share this information with providers
Throughout the year, there have been several goals that Jefferson Health has addressed. The health system has taken on unnecessary care variation by creating a data operationalization strategy aimed at understanding the drivers of clinical and cost variation in practice, facilitating an oncology navigation team to focus on care coordination and outcomes and outreach, and implementing a pathway system.

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