On July 1, 2012, Innovative Oncology Business Solutions and Barbara McAneny, MD, chief executive officer of New Mexico Cancer Center, were awarded a $19.76 million grant from the Center for Medicare and Medicaid Innovation (CMS/CMMI) to develop a community oncology medical home model and implement that model in seven practices across the country. This award represented the culmination of several years of research and development by Dr. McAneny and the staff of New Mexico Cancer Center (NMCC).
The seven community oncology practices participating in the Community Oncology Medical Home (COME HOME) program include:
- Austin Cancer Centers, in Texas;
- Center for Cancer and Blood Disorders, in Texas;
- Dayton Physicians Network, in Ohio;
- New England Cancer Specialists, in Maine;
- New Mexico Cancer Center, in New Mexico;
- Northwest Georgia Oncology Centers, in Georgia; and
- Space Coast Cancer Center, in Florida.
The goal of COME HOME is to improve health outcomes, enhance patient care experiences, and significantly reduce the cost of care. Dr. McAneny and NMCC believe that this is possible by providing timely and coordinated care that keeps patients out of the emergency department (ED) and hospital as much as possible.
Comprehensive Outpatient Cancer Care
COME HOME clinics deliver all outpatient cancer care, which includes triage, diagnostic, and therapeutic pathways, as well as provide patient education and medication management–counseling services. The program allows for team-based care with 24/7 access, including evening and weekend clinic hours. There are also onsite or near-site imaging, laboratory, and pharmacy services. For patients who require hospital admissions, the program allows for direct admission to a hospital bed after evaluation at the clinic, therefore avoiding unnecessary wait and testing in the ED. Hospital stay is typically shorter with a definite management plan that addresses the acute symptom. Once the reason for the hospital admission is resolved, the patient is discharged, and further care is provided in an outpatient setting. Figures 1 and 2 illustrate the reduction in ED visits and inpatient admissions NMCC experienced during the COME HOME project.
As a physician at NMCC, a participant in the COME HOME program, I am delighted to provide this service to my patients. I was particularly touched when sitting at the bedside of a dying patient, her family around her, the patient said: “Cancer is a bad disease, but you have made the journey so much easier.”
This was the first time she was admitted to the hospital in the 5 years she battled metastatic breast cancer.
The COME HOME project is a community oncology medical home model, implemented in seven practices across the country, aimed to improve health outcomes, enhance patient care experiences, and significantly reduce the cost of care.
|COME HOME uses a standardized, computer-based decision support tool for first responders and triage nurses that includes algorithms for 38 of the most common symptoms. Supplementing the triage pathways are the 12 clinical treatment pathways intended to help standardize treatment, so outcomes can be reported.|
Patient-centered care is at the heart of the COME HOME program; by providing extended hours and weekend services, the program enables patients to receive timely care in a familiar place.
|The seven participating practices in the COME HOME project will be comparing their quality and cost of care with control-group practices and hospital-based systems in their region.|
“Whenever my husband called [NMCC] because I was feeling ill, he was told to bring me in. The nurses looked at me and knew exactly what to do. I got the care I needed and was sent home to be with my family,” she said.
She then thanked the staff for the wonderful care. This is what COME HOME is all about.
At the heart of the COME HOME program is a professional infrastructure built around the patient and their support system and available at the time of greatest need. Side effects of cancer treatment include dehydration, nausea, vomiting, diarrhea, and fever, among others. These symptoms typically peak in the evening and are frightening for patients and their families. By providing extended hours and weekend services, the COME HOME program enables patients to receive timely care in a familiar place and by people they know. This decreases anxiety and avoids unnecessary testing.
The Triage System and Diagnostic Pathways
The COME HOME program has also provided great satisfaction to the physicians. Evening and weekend call duties have been reduced, improving physician quality of life. Because most patients call with symptoms at the end of the workday, they typically would have had to be sent to the emergency room, where it would take several hours before they were evaluated and a decision made on admission. This meant late-night trips for the physician to the emergency room to admit patients. With the COME HOME program, patients are evaluated at the clinic in a timely fashion and can be sent to the hospital directly from the clinic, if needed.
The triage system used in COME HOME is a standardized, computer-based decision support tool for first responders and triage nurses. There are algorithms for 38 of the most common symptoms. A flowchart of the triage process for a patient reporting chest pain is shown in Figure 3. Figure 4 illustrates the outcomes of the triage process and provides an overview of triage call times.
Supplementing the triage pathways are the 12 clinical treatment pathways. These were developed by physician pathway teams. Each team was responsible for one cancer diagnosis. Treatment algorithms were developed for the management of early, advanced, and metastatic disease for breast, colon, and rectal cancers; non-small cell and small cell lung cancers; Hodgkin and non-Hodgkin lymphoma; pancreatic, thyroid, and neuroendocrine cancers; and melanoma. The members of the team reviewed current literature and available guidelines to ensure that the proposed treatments are in keeping with current standard of care, and the teams meet quarterly to update the pathways. The goal of the pathways is to help standardize treatment, where possible, so outcomes can be reported. Standardization will also allow for determination of cost during a particular period of treatment, for example in adjuvant treatment of breast cancer. This may be valuable information as new models of payment are being investigated in oncology.
The diagnostic pathways are an integral part of the triage and clinical treatment pathways. Built into the triage pathways are the appropriate laboratory and radiologic tests that may be necessary for disease management. The appropriate laboratory, radiologic, and molecular testing required at each stage of diagnosis for the 12 cancers being followed are also incorporated into the clinical treatment pathways. This further allows for standardizing of management, enabling more accurate reporting of outcomes and cost of care.
The seven participating practices in the COME HOME project will be comparing their quality and cost of care with control-group practices and hospital-based systems in their region. Data from CMS/CMMI are currently being analyzed to compare Medicare spending on cancer care before and after the program within the COME HOME network of participating clinics.
In the last 3 years, NMCC physicians have grown to appreciate the true meaning of patient-centered care because of the COME HOME project. A series of videos of patients sharing their stories is available at the NMCC website, nmcancercenter.org/patientstories. Common themes include the strong connections developed with their doctor, reduced stress level for their families, and the wonderful nurses providing care. Patients are grateful for the convenience of having all medical services in one location. They experience laughter, joy, and hope. One patient said NMCC stands for “New Mexico Country Club.”
“I look forward to bringing my husband here for his treatment; I get to be in the company of family and friends,” she said.
The program is in its final year of funding, and we’d like to see it continue. Dr. McAneny is in the process of writing another grant to seek continued funding. We are hopeful that once the findings are published, CMS/CMMI will provide current procedural terminology codes to allow for payment of many of services not billable under our current fee schedule. Commercial insurers also benefit from the savings of the COME HOME program. It is our hope that we may be able to have meaningful negotiations that will allow some of these savings to be shared with the clinics for the continued operation of the program.
Although patients with cancer account for 1.5% of the total population enrolled in commercial health plans, they represent 8% of spending.1 It is our hope that the savings realized by the COME HOME program, coupled with increased patient satisfaction and improved outcomes, will allow for its adoption into new payment models being proposed for health care.
About the Author: Dr. Fontaine is a medical oncologist with the New Mexico Cancer Center. She has been an ASCO member since 2003.
Disclaimer: The project described was supported by Grant Number 1C1CMS330960 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. These findings may or may not be consistent with or confirmed by the independent evaluation contractor.