COME HOME Project: The Center for Cancer and Blood Disorders Experience

COME HOME Project: The Center for Cancer and Blood Disorders Experience

Amanda Hodges, BSN, RN, OCN

Cindy Glickman

The Center for Cancer and Blood Disorders (CCBD) is a comprehensive community oncology practice with nine service sites that has provided services to patients with cancer and hematologic disorders in the Fort Worth, Texas, region for nearly 30 years. CCBD strives to be on the cutting edge of oncology care.  Our vision is to create and maintain the premier community cancer center in the region, ensuring that each patient’s journey includes high-quality, integrated access to all components of cancer care.

CCBD was approached in 2011 by Barbara McAneny, MD, asking if we would be interested in participating in an innovative medical home model called the Community Oncology Medical Home (COME HOME) project. This, of course, sparked our interest, and we saw it as a way to re-energize our practice and increase our focus on streamlining the patient care process.

Key Points
The Center for Cancer and Blood Disorders (CCBD) is participating in the COME HOME project, an innovative medical home model with the goal of improving health outcomes, enhancing patient care experiences, and significantly reducing costs of care by keeping patients out of the emergency department and hospital as much as possible.
Key changes as a result of the COME HOME project include centralization of first responders for all nine locations, the addition of dedicated triage nurses, expanded patient access to services by adding evening and weekend clinic hours at CCBD’s flagship location, redefinition and redesign of the nurse navigator program, and the creation of a new Survivorship Clinic.
Recognizing the added value of the positions created based on the concepts of the COME HOME grant, CCBD is currently examining how to maintain the infrastructure once the grant funds are exhausted.

The goal of the COME HOME project is to improve health outcomes, enhance patient care experiences, and significantly reduce costs of care by keeping patients out of the emergency department and hospital as much as possible.

According to the Centers for Medicare and Medicaid Services (CMS), more than 1.6 million people are diagnosed with cancer each year in the United States, and many of these individuals are Medicare beneficiaries.1 The current payment structure is proving to be unsustainable because of increasing costs and decreasing reimbursement. More community oncology practices are being absorbed into hospital systems, accountable care organizations, the US Oncology Network, or dissolving completely. As the only remaining large, independent oncology practice in the Fort Worth area, we were searching for ways to remain a viable, productive, and comprehensive option for patients with cancer.

CCBD: On the Cutting Edge of Oncology Care

CCBD has a history of being on the forefront of change in oncology. Our culture has always placed the patient at the center of our care model, and our physician leaders recognized early on that there were opportunities for us to use technology in support of that patient focus. Consider the following highlights:

  • In 1998, CCBD became the first oncology practice in the United States to implement an oncology-specific electronic medical record.
  • In 1998, CCBD became the first
    practice in Fort Worth to offer
    pharmaceutical-sponsored clinical trials.
  • In 2005, CCBD built a flagship center to provide comprehensive cancer services to patients, including a retail pharmacy, radiation therapy, advanced imaging, a CyberKnife Robotic Radiosurgery System, a laboratory, and other integrated support services.
  • In 2007, CCBD piloted the University of Pittsburgh Medical Center clinical pathways program, which is now available as Via Oncology Pathways.
  • In 2009, CCBD began participation in phase 1 of the United Healthcare Episode of Care Project, which piloted a bundled payment model. We are currently a few months into phase 2 of this program.
  • In 2011, CCBD implemented a patient portal in order to share education and clinical information directly with patients.
  • CCBD was the first oncology practice in Fort Worth to provide patient navigation for patients with breast cancer.
  • CCBD was the first oncology practice in Texas to become QOPI® Certified.

As CCBD anticipated the creation of a medical home–type payment structure, participation in the COME HOME project was a natural step for the practice to take. We recognized that we needed to be as prepared as possible for the uncertain future.

As Barry Russo, MBA, chief executive officer of CCBD, stated, “It is clear the current fee-for-service reimbursement structure has a short shelf life. We know the new reimbursement systems will focus on shifting risk and aligning incentives for payers, employers, patients, and providers.”

Implementing the COME HOME Model

Our administrative management team saw the inherent value of participating in the COME HOME model. Once the grant contract was finalized, a multidisciplinary committee was formed to analyze the infrastructure required to support the model. This committee included team members from all departments and satellite locations to ensure standardization of services for patients across all service sites. Integration of the COME HOME project goals has not been easy from a people and process standpoint, but the work is ongoing, and we see the results now embedded in our culture.

Dedicated triage nurses

The first operational modification was the centralization of first responders for all nine locations and the addition of dedicated triage nurses. Triage is housed outside the clinic area and is focused on answering individual patient calls, which supports decision making without clinic distraction. The addition of triage nurses immediately redirected patient calls from individual service sites, which significantly reduced clinic staff interruptions and allowed clinic staff to focus on in-person interactions.

Triage nurses use a symptom-management pathway system using evidence-based protocols that was developed specifically for practices participating in COME HOME. The software-based system originally included 23 pathways but has since expanded to 37. By using set pathways, the symptom management and resolution is standardized and supported by evidence-based practice. This allows the triage nurse to assess the patient and recommend appropriate care, which may include a same-day, acute-care visit.

The addition of triage nurses was a new concept for patients and caregivers and required education and reassurance. Standardizing the new processes across nine locations required some creative design and continued reinforcement.

Expanded hours

One of the attributes of the COME HOME model is expanded patient access to services. Even before enrolling in the COME HOME project, CCBD had 24/7 telephone access to providers, which continues today. Because of the COME HOME project, our flagship location added evening and weekend clinic hours. The evening clinic is staffed Monday-Friday by a front office member, a registered nurse, and an advanced nurse practitioner. Weekend clinic hours are staffed by the same team with the addition of a medical assistant. Offering these services at all nine locations was determined unfeasible because of staffing cost and other limitations. Our flagship center is the only location offering extended evening and weekend hours at this time.

Providing evening and weekend clinic hours has proven beneficial in many areas. Patients now have the ability to come to the clinic for assessment, required injections, hydration, antibiotics, pain management, and other acute services, which has reduced the number of costly emergency room visits and hospital admissions. The structure has proven to be financially sustainable under our current payment model, which could effectively transfer to new payment models.

Nurse educators

The implementation of the COME HOME project created an opportunity for CCBD to use a registered nurse in a nurse-educator role and for case management care coordination. The care coordination team consists of one administrative staff member and one oncology-certified nurse supported by strategic members of the management team. The care team works to coordinate the care of approximately 250 patients identified by diagnosis and treatment plan. The nurse educator meets with each patient in person or by phone at specific milestones in their care. During these interactions, the nurse assures that appropriate referrals are made to support services, treatment decisions are understood, side effects are effectively controlled and/or prevented, and all questions are addressed.

This program led to a redefinition and redesign into a nurse navigator program. Previously, the nurse navigators were event organizers, patient greeters, and, occasionally, resource directors. Under the COME HOME model, our navigators now assist in the preparation of new patient medical records and history information. They also meet with each new patient by phone or in person to introduce them to CCBD prior to the first clinician visit. Navigators serve as the patient’s first introduction to the oncology medical home concept. They are focused on patient education with coordination of care within our practice and with outside referrals. They also help facilitate all patient-centered programs for patients and caregivers hosted at our service sites. For example, when opportunities through community partners are available, such as Reel Recovery and National Cancer Survivors Day, the navigators encourage patients to participate.

Survivorship Clinic

Our newest initiative is the Survivorship Clinic, which is currently in its infancy. Historically, patients were referred out to a community-based survivorship program, but this process was inconsistent. In support of the medical home concept, the Survivorship Clinic was determined to be integral to our continued patient relationship.

Several nationally available structured programs were examined. Some had cumbersome functionality, some were less robust than we wanted, and some were cost prohibitive. The survivorship team, which was comprised of advanced practitioners and registered nurses, developed in-house documents for a customized program. It uses a combination of electronic health record templates, incorporating patient treatment history and a summary of care document extracted from the Via Oncology Pathways system. In September 2014, CCBD saw its first survivor using this new program documentation. A full multidisciplinary approach is currently being evaluated using social workers, dieticians, and physical trainers.

Next Steps

The initial COME HOME project grant period will end June 30, 2015. CCBD is examining how to maintain the infrastructure developed once the grant funds are exhausted. We recognize the added value of the positions created based on the concepts of the grant including triage nursing and nurse educators, but we must reallocate funds from other areas to continue to support these positions.

The COME HOME project created an opportunity to partner with Aetna in their oncology medical home pilot. This pilot, which began in March 2014, has already shown very promising preliminary results, including a recognized reduction in emergency room visits and in overall cost of care.

We are also working to secure partnerships with payers on innovative payment models. We are hopeful that payers will recognize practices that demonstrate high-quality care while effectively controlling internal and external costs. This model requires maintenance of a tight practice infrastructure with strong clinical and administrative leadership supporting the goals of a medical home. Full use of data in electronic health records and other automated systems, such as portals, practice-management systems, payer shared-claims data, and comprehensive data review, is crucial to demonstrating the effectiveness of these models.

CMS Oncology Care Model

The CMS Innovation Center has published the new Oncology Care Model, which “aims to provide higher quality, more highly coordinated oncology care at a lower cost. Under the Oncology Care Model, practices will enter into payment arrangements that include financial and performance accountability for episodes of care surrounding chemotherapy administration to [patients with] cancer.”2

CCBD’s involvement with the COME HOME, Aetna, and United Healthcare projects has uniquely prepared us for participation in other medical home models. The CCBD leadership team is currently evaluating the criteria for participation in the CMS Oncology Care Model and is actively working toward accreditation by the Commission on Cancer Oncology Medical Home Accreditation program, and CCBD expects to be one of the first accredited community oncology programs in the United States.

“The provider faculty now sees our longstanding vision coming to fruition and supports our mission of caring for every patient as we would a family member,” said CCBD President Ray Page, DO, PhD. “Our commitment to the integration of new ideas and high-quality patient care has allowed us to focus on each patient and remain financially viable for this exciting and challenging period in health care.”