A Place Patients with Cancer Can Call Home, Part 2: Page 2 of 2

July 14, 2016

FRMC: And, just as it is with kids, there probably continue to be stumbles along the way, correct?

Well, sure, but we spot the problems more quickly. For example, at 1 of our 3 sites, ER utilization and hospital admissions increased over a 6-month period. We assessed the work flows and found out that physician productivity was affected by a family member’s health issues. We also discovered that we needed another nurse practitioner at the site. These issues had not been identified previously. But, we were able to fix the problem and lower the rate of ER visits and admissions.

FRMC: Was your ability to identify and address the problem primarily due to you having access to data?

Yes. When you have data systems and can measure and monitor performance metrics, you can address issues in a timely fashion.

Oncology PCMHFRMC: Can you provide a couple of other practical examples to give our readers a sense of how your oncology PCMH operates day to day? 

A patient may walk into a primary care physician’s office with a persistent cough, and a chest x-ray shows a spiculated lung lesion that is likely to be malignant. In our model, the primary care provider calls one of our physicians. He might say: “I’ve been seeing this patient for years. He has these comorbid conditions and a probable lung. He hasn’t had a biopsy yet, but he’s very symptomatic. He has chest pain and a cough that’s keeping him up all night. Can you see him?”  

Our answer in an oncology PCMH model is, “Yes!” The patient will typically be seen within 24 hours; the available data will be reviewed, the differential diagnosis and rationale for further evaluation will be discussed, all appointments will be scheduled, and the patient’s symptoms will be managed. The patient leaves the office with a diagnostic and symptom management plan—knowing that our practice is the point of first triage from that moment on. 

FRMC: What other improvements to patient care can you cite other than that you are able to see the patient quickly? 

In this example, our team will schedule all the pertinent diagnostic tests and specialty appointments. Just as important, we’ll track every single event that we scheduled, and patient navigators will follow up, assuring completion and retrieval of all outstanding reports.

Once a diagnosis is confirmed, we develop a multi-disciplinary treatment plan. Basically we compress the timelines to symptom management and to treatment. 

FRMC: And what about for someone who comes into the ER?

It’s the same concept. Take a patient who presents in the ER with abdominal pain and for whom imaging reveals a pancreatic mass: we want that patient in our office the next day. Our goals are to relieve their symptoms and launch a diagnostic plan. Prompt expert symptom control reduces ER visits and hospital admissions. 

And, once a patient is in our care, we want him or her to understand that our office is the point of first triage. Last year, 83% of symptom-related calls from our patients were managed at home via the phone.

FRMC: That’s incredible. So I take it that this process doesn’t occur in many oncology practices.

There is significant variability in many practices and programs regarding: access, acceptance of responsibility for symptom management, scheduling  and tracking of tests/external appointments, communication with patients and stakeholders, and the coordination of care. 

This model provides a framework for a medical home—a consistent and reliable source that can meet and coordinate all cancer care needs.