Building Comprehensive Community Care Through Service Line Expansion

Delivering comprehensive and high-quality cancer care in the community is crucial, with estimates showing that nearly 80% of patients with cancer receive care in nonacademic settings.¹ At this year’s Patient-Centered Oncology Care conference, a panel of experts talked through their experiences adding cancer service lines at community practices to keep care within the community and improve the patient experience.

“Expanding service lines beyond traditional infusion in the clinic visits is critical to independent community oncology and every cancer center, but it also helps strengthen community and [helps] our viability,” PCOC cochair Kathy Oubre, MS, chief executive officer at Pontchartrain Cancer Center and associate editor of Evidence-Based Oncology, began.

At Pontchartrain, multispecialty infusion was one of the first nononcologic service lines introduced at the behest of local neurologists, who lacked the ability to infuse natalizumab, a multiple sclerosis therapy, but did not want to send patients to the hospital for treatment. It made sense, Oubre said, and so the practice began multispecialty infusions. Now, they provide this service for about 15 drugs across neurology, dermatology, rheumatology, and orthopedics. Offering these infusions benefits both the community physicians and their patients, who would rather receive treatments in the community vs the hospital.

Joining Oubre in the discussion were Jeff Hunnicutt, chief executive officer at Highlands Oncology of Arkansas; and Jennifer Pichoske, MS, EMBA, AOCNP, chief executive officer at Hematology Oncology Associates (HOA) of Central New York.

Pichoske reiterated the utility of providing nononcologic infusions, sharing that neurologists were also the catalyst for HOA to offer this service but that it has since expanded the list to a variety of specialties.

“I could also say that there’s more value added vs return on investment, like with dietary counseling, social work, or physical therapy,” Pichoske said. “…I feel like there’s a constant evaluation in the community to see what service line would help keep the patient at the center and bring them everything they could possibly need.”

Hunnicutt also highlighted the benefits of being a good partner to fellow community providers and with local nonprofits dedicated to different conditions. Hosting events in tandem with societies can show that a practice is willing to expand beyond the basic oncology services.

“It’s an opportunity for branding to show that you’re a partner, you’re a collaborator, inside of your region, outside of just oncology,” Hunnicutt said, “and I think that’s something that can’t be understated.”

In the same vein, Pichoske emphasized the importance of marketing all service lines, including to fellow self-funded employers and larger employers, to explain the service lines and the ways in which receiving this type of care in the community setting can improve the patient experience and reduce the cost of care.

Maintaining Continuity of Care Between Practices

For nononcology patients, Oubre posed the question of how practices ensure that referring providers stay informed about the treatment a patient received and maintain the relationship and continuity of care. At Pontchartrain, a series of forms gets the job done. Pichoske said that at HOA, they have a navigator who handles communications and care coordination for the nononcology infusion line.

Hunnicutt explained that at Highlands Oncology, most of that work is taken care of by technology. Care coordination is handled automatically through the electronic medical record (EMR) once a visit is completed, by specifying the referring provider in the EMR. Any notes or documents for that provider are then automatically sent out through either fax or a digital exchange using a Continuity of Care Document.

In recent months, artificial intelligence (AI) has also been implemented into care coordination, Hunnicutt said. When a communication goes out to another provider indicating a next step, AI can automate the process of ensuring those steps are executed, including reminding referring providers about pending tasks such as requested follow-ups that have not yet been completed.

AI has also been a game changer for nonclinical tasks, such as scheduling, Hunnicutt said. Highlands utilizes an infusion scheduling platform to assist with scheduling infusions, labs, imaging, and other services. These platforms integrate with the EMR and recommend the most schedule-friendly slots. This technology enables all schedulers to schedule infusions vs specialized schedulers for chemotherapy and infusions, Hunnicut explained.

Accommodating the Shifting Cancer Therapeutic Landscape

Both Pichoske and Hunnicutt noted the importance of offering the latest therapies in the community, even when they complicate processes. These include therapies like radioligands and bispecific antibody therapies. HOA was the first practice in New York to stand up completely outpatient bispecific antibody therapy, Pichoske said. However, she noted that payers are not reimbursing them for having resources like a physician, advanced practice provider, or nurse coming in 24/7. The bulk of the work to operationalize these services was not policy- or procedure-related but was getting a local hospital on board and developing a system for coverage, she added.

“These are service lines, but if we don’t stay current, we’re not doing what’s right for the patient, keeping them at the center,” Pichoske said. “And therapies, as you all know, are changing so rapidly that we are really tasked to do whatever we can to innovate and get this in our doors so patients can be treated in their hometown.”

When adding new lines of service, Hunnicutt’s practice considers what they’ve termed “CAP”: clinical implications, administrative or operational considerations, and pricing. These factors encompass how a line of service will impact the way the practice cares for its patients, what needs to be done from a process standpoint to accommodate that service, and understanding the financial implications of providing that service. New lines of service are not always profitable, he noted, giving the examples of palliative care and physical therapy at his practice.

“They’re loss leaders in our practice, but it’s still an important part of that process to walk through, so you know what you’re getting into, and you can assign, ‘What’s the adjacent value that we’re going to get out of this service line that justifies the loss or the level of the gain?’” Hunnicutt said. Pichoske also emphasized the importance of gaining internal buy-in before launching a new service line.

In closing, the panelists all agreed on the need for financial counselors, who do not generate revenue for the practice but enable patients to stay on therapy and stay in the community, as Oubre explained.

“It’s work to get them the foundation help,” Pichoske said. “There [are] layers of work. But if somebody wasn’t keeping pace on that and watching that, patients would not be able to stay in the community or get the care where they want, so it’s such a high priority.”

Hunnicutt argued that financial counselors can benefit the practice financially, because at his practice, the alternative to patients receiving those resources is that they’ll still treat the patient anyway and give them a drug for free.

“That’s definitely a loss,” Hunnicutt said. “Maybe you’re getting drug replacement, but all the time we spent mixing, delivering infusion with the nursing staff, scheduling all that, it’s all for naught—you’re losing every single time that you’re giving a free drug as a practice. If you’re able to connect them with financial aid to where they’re actually able to pay for these treatments, it’s a financial benefit to the practice, not to mention you’re reducing financial toxicity to the patient.”

Reference

1. Kirkwood MK, Hanley A, Bruinooge SS, et al. The state of oncology practice in America, 2018: results of the ASCO Practice Census Survey. J Oncol Pract. 2018;14(7):e412-e420. doi:10.1200/JOP.18.00149