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value-based care: value-based care
As early as 2007, my colleagues and I at the Center for Cancer and Blood Disorders (CCBD) came to a realization: the standard fee-for-service model was no longer sustainable. As our reimbursement pool diminished, we were faced with a choice. We could do nothing and hope for the best, or we could completely transform how we deliver patient care.
The “do nothing” approach was not an option; we were unwilling to sacrifice the high-quality care we have been offering patients in Dallas/Fort Worth for more than 30 years. As an independent community cancer center with nine locations, 28 providers, and 185 dedicated staff, we strive to be at the forefront of oncology care; we treat more than 200 new cancer patients each month and work hard to provide the best experience for every one of them.
And so, venturing into uncharted territory, we knew our only choice was change.
Nearly a decade later, I can report that the changes we've made—some sweeping, some subtle—have benefited our patients and our staff tremendously, and in ways we could not have predicted.
Today, patients who might have landed in the ER receive treatment right away, before their symptoms reach the crisis point. Nurses who were previously overwhelmed can focus on the patient sitting in front of them, and physicians have fewer calls to make at the end of each day. To our surprise, we've not only achieved these goals but—more importantly—we've improved the overall patient experience.
None of this happened overnight or without struggles. But we've been able to successfully navigate this new healthcare landscape by committing to a two-pronged strategy: remaining flexible and embracing technology.
The Pilot Phase: Nothing Lost, Much Gained
The first step in our journey was participating in pilot programs that were putting value-based models into practice. Our goal was to learn about, prepare for and, more importantly, have a voice in shaping these new models of care. Toward that end, we joined the United Episode Pilot, COME HOME project, and Aetna Oncology Medical Home, all designed to foster a comprehensive approach to care.
These pilots highlighted flaws in our system. Until this point, our infusion nurses taking triage calls typically could not return patient's calls until the end of the day, a practice that not only left some patients waiting an entire day but that also was disruptive for the nurses, who were already overwhelmed with patients sitting right in front of them. Asking these nurses to divide their attention was not a solid, long-term strategy for the patient-centered care approach we wanted to provide our patients.
During these pilots, we took four steps to centralize our triage:
- Hiring dedicated triage nurses to take patient calls. These nurses triaged all phone calls, whether patients were inquiring about appointments, billing, or symptoms.
- Creating a dedicated triage space. We designated a room in our administration area for the triage nurses to work without distraction, away from the infusion area.
- Setting up triage workstations. Our triage nurses had two screens: one opened to the EMR, to ensure we had current information, and the other opened to care-management software designed for recording patient interactions.
- Identifying new metrics for success. Previously, the metrics for success for nurses was to care for the patients in front of them and get phone calls returned. Now they are measured by reductions in ER visits, hospital utilization, and more timely management of acute patient issues at home.
In hindsight, these were logical solutions, but at first, the nurses resisted them. Our nurses take pride in cultivating strong patient relationships and wanted to remain the sole touchpoint for their patients. They worried that introducing additional staff might diminish their relationships with patients, leaving them feeling shuffled around or disregarded.
But we found the opposite. Patients overwhelmingly felt more supported, welcoming the chance to speak with a nurse at any time. Our infusion nurses agreed nothing was lost and much was gained.
During these pilots, we were able to reduce the total cost of care and the number of ER visits. Clearly, the new model was working. But there was a catch: these pilots were completed with a small subset of our patients. As we geared up for the Oncology Care Model (OCM), we needed a way to replicate our success across our entire patient population—without adding costs. The solution was clear: go high-tech.
Keeping Tabs on Vulnerable Patients
Our center has always been eager to adopt innovative technology. In 2010, we began using an oncology-specific patient relationship management software platform to more fully engage our patients, providing them with electronic access to their health information and personalized education. In 2015, we piloted a patient-reported mobile application, which prompts patients to report how they are feeling via text message.
When it came time to fully transform our triage process, we felt confident using additional technology to do it.
Centralizing triage helped our nurses prioritize high-risk patients, but that wasn't enough. For the next steps—assessing, resolving, and documenting each patient incident — staff were left largely on their own. Given that cancer drugs have a myriad of potential side effects and corresponding treatment pathways, it's simply too big a burden for nurses to keep track of them all while staying current on best practices.
We felt patients would be better served if we also standardized the way we managed symptoms. So we worked with our technology partner to develop a new content module for symptom management and embedded this content into their triage and care management software.
Symptom management pathways allow our nurses to provide consistent care when managing common side effects. Let's say a patient calls to report a symptom such as pain, vomiting, or diarrhea. Our nurses walk the patient through questions laid out in the template—for instance are you experiencing pain, is your pain intermittent or continuous, where is it located—and select the appropriate response from a list. These clinically valuable pathways use branching logic; staff are prompted with new questions based on the patient's response, so they can probe more deeply and provide the best treatment.
Our triage nurses report that the software enables them to do their job better. “I can quickly tell whether I can help a patient over the phone or if I need to schedule the patient to see a clinician,” noted triage nurse Noshia Conerly.
The software also enables us to keep more comprehensive records; at a glance, we know who cared for the patient, the details of the encounter, and the resolution reached. This information is automatically sent to both our EMR and the patient record. With the whole care team on the same page, our triage nurses feel more empowered to act on a patient's standing orders rather than having to consult a physician. Patients receive faster care, and physicians have fewer follow-up calls to make at the end of the day.
“Our triage nurses get to know our most vulnerable patients personally and often will preemptively manage problems, keeping them healthier during chemo,” observed Ray Page, DO, PhD, President & Director of Research at CCBD.
Prompting Patients to Report Symptoms
But we didn't stop there. Though we could now respond to patients faster and more consistently, we also wanted to proactively monitor our patients—to find out about symptoms they might not even think to report. Again, to achieve this goal without adding staff, we turned to technology: a mobile application that enabled us to remotely monitor patients.
This tool lets us watch for problematic side effects among our high-risk patients, such as those starting a new oral medication or IV medication. Using clinically validated content translated into patient-friendly language, the app sends an SMS text to patients, prompting them to report how they are feeling. Their responses are instantly stratified by risk to a dashboard monitored by our two dedicated triage nurses.
It's hard to overstate the difference this app has made for our patients. For years, patients would land in the ER because a side effect or symptom had become too severe—severe vomiting or diarrhea left untreated for too long. As a result, their treatment might be delayed, discontinued or switched, compromising their outcome. When we would ask patients why they hadn't notified us immediately, they'd say, “I thought I would feel better soon” or “I didn't know I needed to call.”
That doesn't happen anymore. We're able to catch patient issues, both large and small, which has improved our patient care.
Amanda Hodges, Director of Clinical Programs, recalled the following. “A patient last week had symptoms of a pulmonary embolism but we were able to identify and intervene quickly because the patient reported symptoms. Another patient reported mouth tenderness and we called right away to provide support. Both patients had positive impact, one was profound as we saved their life and the other smaller, but still important as the patient didn't have to suffer at home thinking it was normal.”
More Insight, Better Data
The changes we've made not only directly benefit our patients but also provide valuable insight into how we operate as an organization. We have much more data at our fingertips. We know how many patients call our practice and why they are calling down to the side effect they are experiencing or their need. We know how many proactive and reactive calls our triage nurses manage overall and by staff member.
With such robust reporting, we're better able to document our work, comply with different programs, and identify ways to continuously improve. We will be much better equipped, in 2017 and beyond, for OCM reporting on patient-centered care activities, including the PQRS quality measures, navigation, care plans, depression, and pain.
Adapting to change is never easy—for individuals and for organizations alike.
New technology can be daunting, and you have to plan for a learning curve. But thanks to the pilots we joined and the software we've adopted, we feel well-prepared to navigate the ever-shifting healthcare landscape and look forward to tackling whatever challenges lie ahead.
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BARRY RUSSO, MBA, is CEO of the Center for Cancer and Blood Disorders in Texas.
Barry Russo, MBA: Barry Russo, MBA
