Speakers at the 2017 Community Oncology Alliance (COA) annual meeting in National Harbor, Maryland, reflect on challenges in the first year of the OCM.
Robert Baird Jr., RN, MSA
Implementation of the Oncology Care Model (OCM) from CMS has involved technological challenges, as practices have scrambled to find seamless solutions to bridging old electronic health records (EHR) with new “patches” designed for the OCM. It has also involved coaxing oft-reluctant staff members to adapt to new ways of performing. Speakers at the 2017 Community Oncology Alliance (COA) annual meeting in National Harbor, Maryland, said these difficulties were not insurmountable, in reflections on the first year of the OCM, titled “Lessons Learned.”
The 2017 Community Oncology Conference discussion featured Robert Baird Jr., RN, MSA, chief executive officer of Dayton Physicians Network, in Dayton, Ohio, as moderator. The participating practice administrators were Anne Marie Rainey, MSN, RN, CHC, compliance and control officer with Clearview Cancer Institute, in Huntsville, Alabama; and Alti Rahman, MHA, practice administrator for Oncology Consultants in Houston, Texas.
OCM requirements for greater reporting, performance measures, and more extensive patient care plans were reviewed, and Rahman and Rainey described how they addressed each of these and what obstacles had to be overcome.
Rainey described her practice’s experience with the OCM as a sometimes frustrating process of trying to conform to the new expectations for patient-centered care.
“Some days you feel that you have it really well figured out,” she said. “You’re getting the care plans together, things are going well in the clinic. We feel like employees understand this shift from fee-for-service to value-based care and what that means, and then there are other days when we feel like we are pulling our hair outthat we’ve missed the boat on some of these items.”
Rainey’s clinic has 3 full service locations and 2 satellite locations with limited office visits, 1 day a week. They have 12 doctors and 16 mid-level providers. They also do retail pharmacy and lab work in-house, as well as imaging and genomic testing. They also do radiation and physical therapy at their main location.
Rahman’s practice has 19 providers, including 15 physicians and 4 mid-level providers, working from 9 medical oncology locations and 2 radiation centers. They do oral pharmacy, research, and imaging in-house.
Rainey said there are many elements to the OCM that have had a very positive impact on the way patient care is delivered, but she said many requirements have been difficult to integrate smoothly with standard operations. “Even though there are going to be road bumps along the way, we’re really trying hard to make changes in our practice that are going to be sustainable. That’s true not just for our practice but for the future of oncology care,” she said.
Rahman agreed with that statement, indicating that a good measure of the complexity of a task is the number of gray hairs it produces, and that the OCM has given him a wide swath of gray hair.
Both speakers said their practices had to improve internal communications to make the transformation a success. Staff members had to cross-check one another’s progress toward meeting the OCM goals. Without that key activity, progress was liable to move sluggishly.
Certain members embraced the OCM from the start. Rahman said a successful division of labor into 2 teams1 of which looked at operational aspects of the practice, clinical and nonclinical, and the other, operations—created a counterbalancing force that kept everybody moving forward.
These teams communicated with each other “to make sure that whatever operational processes were being created always led to appropriate reporting. I think that’s helped us to organize the OCM and loop in other quality initiatives instead of having separate work groups that address things more on a project-specific basis,” Rahman said. He said practice administrators sought to create an understanding that the OCM transformation was important, not just for their operations, but for the practice of oncology in general.
Rainey said that in her practice they realized that e-mails weren’t checked regularly by staff, so they held team meetings more often to provide continuous quality feedback on OCM progress. In addition, Rainey visited clinical staff members more regularly to discuss performance and potential improvements. “I also [established] an open-door policy so that people could come in and say, ‘Today was really bad. I didn’t get a care plan done for any of my patients.’” Together they could do joint assessments and arrive at solutions, she said.
She said some staff members embraced the OCM project without resistance, whereas others needed coaxing. Her administration would take what some staffers were doing successfully and try to implement that in sections of the practice that were moving more slowly with the transformation. “There was obviously a disconnect. Some really bought into this and saw the importance, and they understood why we were having to do it, and others thought it was just 1 more thing to add on” to their workload.
However, there has been a significant improvement in staff acceptance in the past 2 to 3 months, which was reflected in such things as care plan completion and advance care directive completion, Rainey said.
When asked about how he communicated the financial aspects of the OCM effort to staff membersspecifically, the importance of performance-based incentives of the OCM, Rahman said that “was an important discussion to have—to make sure that not only were we making progress with our clinical operations, but we were also maintaining how the budget looked so that we could provide that feedback.” He said his practice found that the additional cost in resources needed for OCM implementation was $300,000 for the first year, mainly for staffing for operational and reporting needs.
Rainey said it was important to come to an understanding of how much time and effort individual staff members were putting into the OCM effort and whether additional staffing was needed to complement those efforts. Their operational analysis told them that approximately half of their practice resources were going toward patients on Medicare, so that enabled them to determine how much they needed to invest in their operations to meet OCM requirements. This led to realizations that, “Hey, we do need a nurse navigator for every physician. We do need a medical assistant for every physician, because we want to make sure that we’re able to perform those activities to the best of our ability, and that we’re able to give the time and effort that’s truly needed.”
The strongest challenge of implementation in Rainey’s practice was adapting to the workflow changes associated with the CMS care model. “People don’t like change. They were very comfortable with how they were carrying out their everyday duties. Initially that was a big challenge for us, because to them it seemed like we were just adding paperwork or adding clicks into the care plan,” she said. EHR had made the process easier for them because it had a care plan element built in, which just required additional effort to meet the OCM requirements.
For Rahman’s practice, 1 of the strongest challenges of implementation was finding the resources needed for reporting data to CMS. “There’s an element of manual abstraction of the data,” he said. The practice responded by looking for ways to automate a lot of that work. A second big hurdle was meeting the OCM requirement to improve the communication with patients about costs of care. Patients tended not to understand what was included in the costs that were presented to them, he said.
Rainey agreed that for her practice, cost-of-care estimates were difficult to produce. She said they have worked hard to develop better estimates for patients. “We can’t predict everything that’s going to happen, but we do want to give them something that’sto the best of our ability—true.”
Documentation needs have also added complexity to practice operations, mostly because there is much to keep track of and this consumes a lot of time, Rainey said. “Sometimes we have to spend more time in the weeds of the documents than we would like.”
Software for handling the OCM requirements has presented its own challenges. Existing EHRs provide some support for doing the care process tracking that is needed, but they don’t go far enough in their capability, Rahman said. Many vendors have stepped in with OCM data management systems that purport to fill the gaps in reporting needs; however, these need to be synced up with existing EHR systems. “For patients and doctors, we need to provide a unified experience, but when you’re incorporating these multiple technologies, that becomes really challenging,” he said. There still is what Rahman identified as a “development lag” between what is needed and what tools and capabilities exist.