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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.

It has also worked on guiding patients to the appropriate site of care by looking at how to reduce avoidable emergency department (ED) use. Looking at baseline data on patients visiting the ED who did not got admitted, it found that just shy of 50% of those patients are going to the ED while the clinic is open.

“We saw this as a huge opportunity to say, ‘How can we leverage the triage algorithms that we built for all the different symptoms, and how can we leverage our same-day clinic where patients can be immediately plugged to when they call the practice?’” Chapman said.

The health system, as a response, started an education campaign to educate both providers and patients about the importance of calling the practice beforehand to ensure direction to the appropriate site of care.

Taking on a third goal, the health system opened up the Neu Center for Supportive Medicine & Cancer Survivorship, which this year has screened nearly 900 patients for distress and has facilitated advanced care planning discussions early on between providers and their patients.

Looking ahead, Chapman outlined several challenges for the coming year, including scaling capabilities; implementing programs to manage high-risk or targeted populations; and engaging primary care and specialty practices.

A focus on primary care
Integrating and engaging primary care in cancer care and cancer survivorship has been of high interest to not just Jefferson Health. During IVBM, Kelly Filchner, MSN, director, Fox Chase Cancer Center Partners, walked through how the cancer center integrated primary care into oncology patient management.

“Primary care physicians believe they are an integral part of cancer care but they need the tools to be part of that team,” she explained. For Fox Chase Cancer Center, this plays an especially important role in survivorship.

With the realization that many patients transitioning out of their oncology care did not have a primary care provider (PCP), the cancer center created the Fox Chase Cancer Center Care Connect. The team started by going out and finding and building relationships with PCPs in the area.

It also set clear goals of what value it intended to get out of the program. For providers, Fox Chase wanted to ensure effective access and communication with the cancer center, improve physician metrics, and enhance shared collaboration and support of a growing survivorship population.

For the cancer center, there were goals of improving the transition of patient to survivor; providing an opportunity for screening, risk, and diagnostic services; and dispelling the notion that Fox Chase is only a place for cancer treatment.

“You can’t just create a program and then let it be on its own. You have to constantly be doing something, you have to constantly be monitoring,” explained Filchner.

Currently, the program includes 33 PCP practices representing 50 family medicine or internal medicine physicians and 22 mid-level practitioners. The program also includes 3 obstetricians and gynecologists, noted Filchner. To date, the program has referred 300 patients who did not have a PCP.

 
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