Ideally, the pursuit of a stronger healthcare system involves implementing care improvements that reduce health expenditures. A previous post described how the Oncology Care Model (OCM) attempts to establish incentives for such efforts in the realm of strengthening cancer care.
As part of the OCM, many practices are exploring the impact of opening cancer-centric urgent care or expanded-hours clinics to provide alternative access points for patients with cancer who present with acute symptoms. In addition to chemotherapy (and its side effects that can result in acute care needs 24/7/365), hospital admissions and, to some extent emergency department (ED) visits, are significant drivers of cancer care outcomes and costs in the United States. Cancer patients already shoulder the stress of their condition and have weakened immune systems that can leave them more susceptible to infections. Providing a safe, alternative acute care access point provides real choices for patients and their families.
This post chronicles the pilot launch of 1 OCM practice’s 24-hour cancer clinic.
The Froedtert & the Medical College of Wisconsin (MCW) Cancer Network recognized the need for after-hours care access for patients with cancer prior to the launch of the OCM.
“Patient volumes and acuity were increasing. We needed a better way to manage urgent symptoms after hours,” said Tina Curtis, executive director of Froedtert & MCW Cancer Services. “We wanted our patients to use an oncology-dedicated clinic for urgent concerns as much as possible, recognizing that certain serious conditions like heart attack or stroke must still be addressed in our ED.”
To substantiate the need for a 24-hour cancer clinic pilot, Curtis and her team conducted a comprehensive patient chart review to understand when and why patients presented to the ED.
“We found that most patients arrived between noon and 10 pm, and that at one site, about 65% of patients arrived by car, meaning they were stable enough that they didn’t need emergency transport,” Curtis said. “Of all patients who arrived at the ED, about 50% were admitted. We found that a significant percentage of admissions could be considered avoidable with adequate close outpatient follow-up.”
Satisfied by the data, Froedtert & MCW leaders approved the consolidation of 2 inpatient hematology/oncology rooms into a 24-hour outpatient cancer clinic. The clinic would offer enhanced continuity of care for patients, providing treatment for symptoms such as fever, dehydration, nausea, mouth sores, bleeding, and fatigue. The clinic, now formally named the 24-Hour Cancer Clinic, is staffed by advanced practice providers, oncology nurses, and technical staff.
Implementation: The First 6 Months
As with most new clinical initiatives, the 24-Hour Cancer Clinic did not operate at full capacity with the flip of a switch. Curtis and her team conducted considerable patient and provider education following clinic launch in November 2016. Patient flyers populated clinic exam rooms and the inpatient oncology unit, and were included in discharge materials. Meanwhile, in addition to small group and individual provider briefings, the clinic added a laminated card containing information—such as which patients to refer to the clinic, how to enter corresponding orders, and who to call with questions—to clinician ID badges. The efforts worked: patient visits to the clinic saw a steady monthly growth (see below).
Results: Patient Satisfaction
As a priority, the clinical team wanted to determine the clinic’s impact on the patient care experience. The team used formal surveys conducted by a vendor, along with information gathered by nurses during follow-up phone calls. Patients were asked about their experience and if the clinic provided value. They responded with overwhelmingly positive feedback, including comments such as: “Things went perfectly…it is nice to have a place like this where people know what I am going through; you know exactly what I need, and you get it done.”
Overall, patients expressed relief at having 24/7 access to clinicians who understood their cancer and their unique care journey.
The familiarity with cancer patients and their care also translated into decreased utilization of certain diagnostic services. When compared with patients who initially presented to the ED and were ultimately sent home, the percentage of 24-Hour Cancer Clinic patients who received lab orders, radiology orders, or cardiac work-ups was lower. In addition, only 20% of 24-Hour Cancer Clinic triage patients are ultimately admitted, compared with a 45% admission rate in the ED.
To date, overall ED utilization at Froedtert & MCW Cancer Network locations appears unchanged. However, the Cancer Network team is early in the process of expanding clinic access beyond patients from hematology and oncology to those from radiation oncology, surgical oncology and other specialties. Further analysis is underway to determine if and how the 24-Hour Cancer Clinic impacts the number and type of patients presenting to the ED.
The Froedtert & MCW Cancer Network hopes to bolster this analysis through the use of Medicare-provided Oncology Care Model (OCM) data, which reflects all care provided to OCM patients—not just the care received from Froedtert & MCW clinicians. In addition, care in the 24-Hour Cancer Clinic has expanded to include not only acute-care patient triage visits but also those with planned follow-up appointments on weekends, patients who need 4-to-8 hour observations for clinical decision-making, patients who need same-day urgent CT scans, and more. Finally, the Froedtert & MCW team is partnering with the Emergency Medicine department to safely implement a process to facilitate transferring eligible patients who initially present to the ED to the 24-Hour Cancer Clinic.
“What cancer patients want is quick access to reliable care from a team of providers that knows about their disease and treatments,” said Parameswaran Hari, MD, a hematologist/oncologist, as well as MCW Armand Quick William Stapp Professor of Hematology and interim chief of Hematology and Oncology.
“The Froedtert & MCW 24-Hour Cancer Clinic ensures that when urgent issues arise, a team of medical providers with instant access to records and specialized oncology expertise are able to see patients within the cancer center space. In close partnership with our Emergency Medicine colleagues, we are working together to help patients get the best care at the right place to maximize outcomes for their cancer.”