Surabhi Dangi-Garimella, PhD, AJMC Writer

In a panel discussion this morning during the Association of Community Cancer Center (ACCC)&rsquo;s 44th Annual Meeting & Cancer Center Business Summit,&nbsp;experts stressed the importance of integrating team-based care to break silos and allow a continued care transition as the move continues toward value-based care.

The panelists shared strategies that have helped their organizations adapt to value-based care while ensuring that they never lose sight of the patient at the center of it all. On stage were Marcus Neubauer, MD, vice president and medical director, Payer and Clinical Services, McKesson Specialty Health and The US Oncology Network; Tricia Strusowski, RN, MS, manager, Oncology Solutions, LLC; Barbara Tofani, RN, MSN, AOCN, administrative director, Hunterdon Regional Cancer Center; and Mark Krasna, MD, corporate medical director, Meridian Health System, Ocean Medical Center, who moderated the conversation.

Strusowski, a nurse by training who now works for a consulting company that advises oncology practices on value-based planning and care design and delivery, dived straight into the strategies that can enhance care coordination. &ldquo;We need to reduce duplication and adapt more real-world strategies,&rdquo; she said, which can enhance patients&rsquo; experiences with their care. &ldquo;It&rsquo;s also vital for practices to identify performance improvement initiatives for programs and services that may not be reimbursed.&rdquo;

In discussing the care continuum, Strusowski highlighted the importance of patient flow and transitions. It is important to share that information with the entire team to decrease duplication of efforts, she said, adding that improving ways to communicate care information to patients and their families is vital to the process.

A study&nbsp;published in the December 2017 issue of&nbsp;The American Journal of Accountable Care found value in a model that used email-based care transitions between a hospital and primary care teams. Researchers found the practice improved patient attendance at follow-up visits, provider satisfaction, and work efficiency.

Strukowski then showed a very long list of members that should make up an ideal care team. &ldquo;The care team should be multidisciplinary, and should include not just clinical and administrative staff, but patients and their caregivers should also be a part of the conversation,&rdquo; she said.

She then suggested several strategies to increase the efficiency of care teams, including daily huddles, morning meetings, and discussing patient cases during tumor conferences. &ldquo;An emphasis on staff training on core competencies, national guidelines, and health literacy is important,&rdquo; Strukowski said, along with developing partnerships with other clinical practices and incorporating performance improvement strategies based on navigation and value-based cancer care metrics. At pre-determined stages, the care plan should include comprehensive patient assessment and patients should be referred to dieticians or counselors as required, she said.

Being cognizant of the patients' and their families&rsquo; situations, Strukowski said that the care team should provide them with shared decision-making aids instead of just handing them a volume of information on treatment options, which might be hard for them to read through and understand. She emphasized the importance of disease-site process mapping to review specific roles within the care team and identifying gaps in care. And, to come full circle, it&rsquo;s important to match these with national quality metrics, she added.

Neubauer provided an overview of the Oncology Care Model (OCM), which funds practice transformation and demands:

Implementation of the Institute of Medicine care plan

At the ACCC meeting, Neubauer explained that the Centers for Medicare & Medicaid Innovation, which has developed&nbsp;the OCM pilot reimbursement program, delivers data files to participating practices on a quarterly basis. &ldquo;The raw data need to be converted to actionable information for practices," Neubauer said.

This information, of course, is vital for process improvement. Neubauer showed analyses of these data conducted by his organization that helped identify patients at high risk of hospitalization following chemotherapy, based on gender and age.

&ldquo;Also, the data can provide a glimpse of risk of hospitalization following chemotherapy, based on disease type. It also gives us the ability to follow patients at higher risk if they have comorbidities,&rdquo; he said. As the bottom line, it can significantly impact proactive case management to reduce these hospitalizations in these specific patient populations.

Evaluation of the impact of ACP on end-of-life choices by patients at their practices showed that 88% of those with ACP died at home or in hospice. In the non-ACP population, 77% died at home or in hospice care.

These data, when fed back into the system, can help practices implement positive changes and create a learning system.

Another growing concern within oncology is caring for survivors and coping with posttreatment health issues. Tofani discussed this as a last part of the puzzle of care coordination and directed the audience&rsquo;s attention to the use of clinical practice guidelines to coordinate survivorship care.

&ldquo;In less than 8 years, there will be 20 million cancer survivors in the United States. Why is survivorship care important?&rdquo; Tofani asked. She noted that cancer survivors are faced with numerous issues, such as recurrence, secondary cancers, psychosocial effects of their disease and treatment, comorbidities due to other chronic diseases, and more.

Hunterdon, Tofani said, developed a survivorship program for better coordination of survivor care that was modeled on the National Coalition for Cancer Survivorship and the George Washington University Cancer Center toolkit&nbsp;and&nbsp;guidelines.

She said that studies have shown that primary care physicians (PCPs) and oncologists are confused about survivorship care and follow-up care, &ldquo;which affects both the quality and cost of care.&rdquo; Tofani said that Hunterdon has promoted their clinical practice guidelines and care coordination among specialists and PCPs as one of the first steps to improve survivorship care in their patient population.

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In a panel discussion this morning during the&nbsp;Association of Community Cancer Center (ACCC)&rsquo;s 44th Annual Meeting &amp; Cancer Center Business Summit,&nbsp;experts stressed the importance of integrating team-based care to break silos and allow a continued care transition as the move continues toward value-based care.

Panelists Highlight Ways to Ease Transition to Value-Based Care

During a panel at the Association for Community Cancer Center (ACCC)&rsquo;s 44th Annual Meeting & Cancer Center Business Summit this morning, experts discussed some of the biggest drivers of change in oncology care, as well as what is in need of the most attention at the present time.

Deirdre Saulet, PhD, practice manager, Advisory Board, led the discussion by introducing findings from the 2017 Trending Now in Cancer Care Survey, which was developed through a partnership among ACCC, the Oncology Roundtable, and the Advisory Board. Saulet was joined on the panel by Jo Duszkiewicz, MSA, vice president and administrator, Renown Health Institute for Cancer; and Mark Liu, director of strategic initiatives, Mount Sinai Health System.

There were several key takeaways&nbsp;from the survey, which had a majority of respondents from nonteaching community hospitals, followed by teaching hospitals and academic medical centers:

The cost of drugs or new treatment modalities (68%), as well as physician alignment around services and program goals (47%), were top threats to the growth of future cancer program growth.

Respondents felt that clinical standardization (63%) and drugs (62%) presented a significant opportunity for cost savings.

Market consolidation was a common theme among survey respondents, with 75% reporting that their group had partnered with an existing hospital or health system and 36% had merged with a private oncology practice.

Regarding information technology, data abstraction and interoperability of electronic health records were listed as significant challenges.

Just over half (51%) agreed that prior authorization had significantly increased in the 12 months prior to the survey.

There exist staff shortages, especially for oncology nurses, medical oncologists, and advanced practitioners.

Saulet then invited Duszkiewicz to share how Renown Health Institute for Cancer has adapted to the changes.

Renown&rsquo;s health system is a combination of acute care, transitional care, network services, and insurance services, Duszkiewicz said.

&ldquo;Understanding where patients are, where they got their treatment, drawing out specifics of treatment into EPIC, and then ensuring we have all the information is difficult,&rdquo; she explained. It is further complicated by the fact that Renown works with many rural community practices, which may be 200 to 300 miles away.

&ldquo;We do practice oncology telemedicine for a few of our communities, in parallel with medical oncologists conducting site visits,&rdquo; Duszkiewicz said. &ldquo;We also link with primary care in those areas. However, we found out that primary care physicians were struggling with diagnosis and the tests that were needed.&rdquo; Consequently, these struggles resulted in an extended time to diagnosis.

To unscramble this situation, Renown developed a solution: the intake oncology coordinator (IOC) process, which included conducting a phone triage first, then a chart review, and finally, bringing the patient in for a clinic visit.

&ldquo;On evaluating the data, we see that 31% of patients get phone advice, and 25% do a chart review, but 44% of patients who are referred come to see the advance practice nurse,&rdquo; Duszkiewicz said, adding&nbsp;that IOC has resulted in a very successful clinic.

Duszkiewicz then presented trends within the fee-for-service reimbursement model from 2013 to 2022, which show that productivity adjustments have been increasing, from $4 billion to $94 billion, she said. The shift now is toward value-based contracts, such as the Oncology Care Model (OCM), alternate payment models, and others.

However, Duszkiewicz asked, are shared savings feasible in oncology? She shared data from the Miami Cancer Institute on the results of adopting a value-based approach to care:

First-year savings were modest: $354 per patient per year (pppy)

She explained that clinical pathway adherence had a significant impact on the savings seen over the first to the third year. However, the diminishing returns of savings in year 4 have triggered more cost savings initiatives within the institute that are focused specifically on the inpatient population.

Next, Liu spoke of Mount Sinai&rsquo;s practice changes. To be able to provide high-value care and broaden patient access, the hospital has developed several projects and programs, including creating disease management teams (DMTs), building clinical pathways programs, establishing a chemo council, and using Epic_Beacon to monitor the clinical pathways being used.

DMTs, Liu said, are focused on quality metrics, value-based care, care pathways, tumor boards, and clinical trials. They are also tasked with narrowing down the quality metrics to avoid overlap and integrating OCM quality metrics with disease-specific metrics for tracking and decision making.

Saulet then spoke about the changing dynamic between the patient and the provider. &ldquo;Cancer patients are acting independently and asking questions,&rdquo; she said. &ldquo;Patients are taking more responsibility for their healthcare costs. Patients have information available at hand on sites of care as well as drugs and treatment. Plus, the patientprovider relation is changingthere are rising expectations on service, with patients feeling more empowered and being skeptical about the care they receive.&rdquo;

Saulet said that patients with cancer are doing their research: 25% of patients who were surveyed said that they are spending an hour on average reviewing oncologists and 41% said they had researched their treatment options.

Precision medicine is also evolving rapidly, Saulet said, with 92% conducting predictive tests, 92% conducting single-gene tests, 72% conducting small panel tests, and 31% conducting whole-genome sequencing.

During a panel at&nbsp;the Association for Community Cancer Center 44th Annual Meeting &amp; Cancer Center Business Summit this morning, experts discussed some of the biggest drivers of change in oncology care, as well as what is in need of the most attention at the present time.

Surabhi Dangi-Garimella, PhD, AJMC Writer | Authors

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