Washington, DC-The COME HOME initiative, a 7-member oncology medical home practice partnership, has documented significant reductions in hospitalization rates, inpatient days, and total cost of care of approximately $5 million over a 6-month period, said Barbara L. McAneny, MD, at the Fifth Annual Conference of the Association for Value-Based Cancer Care.
Dr McAneny is Chief Medical Officer and Chief Executive Officer for Innovative Oncology Business Solutions, the company that manages the COME HOME program. The 7-member partnership of community oncology practices features oncology nurse triage using electronic pathways, outpatient urgent care, extended hours, pathways development with decision support, and real-time outcomes data collection and analysis. The project was funded by the Centers for Medicare & Medicaid Services (CMS).
The initiative "was started in my practice really out of self-defense, in that my patients are going bankrupt, and I have to figure out a way to prevent that from happening while delivering them care," said Dr McAneny.
"The idea was to take the 7 practices, try to improve the quality of care, and get the patient to the right place at the right time for the lowest-cost site-of-service care," said Dr McAneny. "I am after the 10% that go to the hospital in the emergency department, because that is the main part I can control."
Unlike the primary care medical home, in which time and effort are devoted to figuring out which 20% of patients will consume 80% of the practice's resources, all patients managed by an oncology medical home are "expensive patients," according to Dr McAneny.
CMS has decided that in 2016, 30% of all payments in an oncology medical home must be from an alternative payment mechanism, which will increase to 50% in 2018.
Triage Protocols, Team Care, and Clinical Pathways
"We have to be able to get the right test at the right time," said Dr McAneny. "We have to be able to know that we have the decision support, because there is not an oncologist on the planet who is going to be able to keep track of all of the various mutations and all of the drugs, and be able to get the right drug to the right person."
The tools to achieve the goal include triage protocols, team care, and clinical pathways, which will soon incorporate genomics, which promises to be a major expense in the future. Other features designed to improve the delivery of patient-centered care are after-hours clinics, same-day appointments, and patient education.
The practices selected for COME HOME all had electronic health records, and a software system was created to pull data from the records, feed the data to providers, and update the data nightly so that real-time data are available.
The triage pathways are intended to manage the symptoms of cancer and cancer therapies, Dr McAneny explained, and pathways have been generated for 30 symptoms to provide decision support for clinicians. The hypothesis is that aggressive symptom management at the practice level will reduce emergency department visits and hospitalizations. Same-day appointments are available for antibiotic prescriptions, fluids, and acute follow-up of reported symptoms.
"The main thing with the triage system is that you have to give the oncology nurses...the power of the schedule," Dr McAneny said. "When patients say 'I'm sick,' you have got to get them in now. Ideally, you back it up to where you can interfere with their disease process, before they get so sick that they have no choice but admission."
Practices must be able to function as urgent care centers, "which means that if somebody comes in and has symptoms of a pulmonary embolism, I can get a CT [computed tomography] scan that is high resolution, with a turnaround time of an hour," Dr McAneny said.
The diagnostic and therapeutic pathways are physician-generated, with academic help, and include imaging and genomics. Pathways allow the aggregation of data to follow outcomes and toxicity and, eventually, cost data. They also prove that quality care occurs without chart abstraction.
Six-Month Data Support the Effectiveness of the Model
All participating practices in the COME HOME initiative now offer evening and weekend hours. The number of extended-hours visits has been climbing among the practices, to a median of 82.5 (Figure 1).
Compliance with the triage pathways in the 7 practices improved from approximately 55% to approximately 75% during 6 months.
The triage pathways have paid off in the form of fewer hospitalizations for all active patients (Figure 2). The overall patient satisfaction rate was a median of 91%.
Medical service data from the New Mexico Cancer Center show that the rate of patients with emergency department visits fell by 35.9%, the rate of inpatient admissions dropped by 43.1%, and the number of inpatient days declined by 2.8% since the institution of the medical home, resulting in a $4784 (22.4%) decrease in total cost of care per patient during the 6 months.
Compared with contemporaneous data from the Albuquerque metropolitan area, COME HOME patients are 50.2% less likely to visit an emergency department, are 43.6% less likely to have an inpatient admission, spend an average of 2.71 fewer days in the hospital, and cost Medicare $2149 (11.5%) less.
Based on these data, the projected average savings to CMS is $4178 per patient.