Attendees at the 2015 Association for Value-Based Cancer Care conference heard Robert “Bo” Gamble, Director of Strategic Practice Initiatives, Community Oncology Alliance (COA), describe recent accreditation initiatives for the oncology medical home (OMH) model.
The movement toward formalization of the OMH concept started in mid-2011, when COA formed its first OMH Steering Committee, which encompassed 19 diverse members from different perspectives, including payers, providers, the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), the National Patient Advocate Foundation, patients, and pharmacists.
The challenge to the OMH Steering Committee was to explore “what do we need in cancer care,” said Mr Gamble. The OMH Steering Committee met in 2012 to develop a list of 16 measures and then organized a team of 8 practice administrators to explore solutions and transitions toward the OMH concept.
The medical home model was not new to other specialties, particularly primary care, but it needed consideration on how previous models could be adapted and improved to meet the needs of the complex oncology care system. The OMH Steering Committee decided to pursue an accreditation process to better align the goals of quality, value, and outcomes with a formal process that oncology practices could adopt to not only pursue greater value and quality, but be able to receive formal recognition of that new standing.
Accreditation Process
Ultimately, the American College of Surgeons Commission on Cancer (CoC) agreed to work with COA on designing an accreditation program for the OMH. The groups focused on 5 distinct domains that attempted to meld quality with value concepts—a novel pairing for the traditional accreditation model. After a year of development and testing of standards and the manuals and policies to accompany those standards, 10 pilot practices tested the practicality of operationalizing those standards and policies.
The participating pilot practices included leading practices from Florida, Georgia, Maine, Missouri, New Mexico, New York, Ohio, and Texas, many of whom were also participating in the COME HOME OMH project developed by Barbara L. McAneny, MD, Chief Executive Officer, New Mexico Oncology Consultants, Albuquerque, under a federal innovation grant.
The eligibility criteria for this evolving accreditation program seem simple, but are in fact quite complex. Mr Gamble even noted that they could almost judge the success of a pilot program with how well practices addressed meeting the following eligibility criteria:
- The entire cancer care team supports and promotes the OMH. Some practices started with a kickoff meeting to present the concepts and encourage discussion across the team. The practices that generated a lot of discussion found it easier to move forward with the process. When the topic was opened, and those in the meeting turned and looked to one team leader to start talking, it seemed as though those practices had a more difficult time. When everyone in a practice showed excitement about the program and the transformation, the pilot programs went well and the buy-in emerged from top down as well as bottom up.
- Certified electronic health record (EHR). There is still great variation in EHR systems, but to move forward with a successful OMH initiative, a practice should have a functional certified EHR system.
- Submitting data that demonstrate compliance. It is clear that verbal assertions of quality from healthcare providers now have to be replaced with demonstrable, reportable measures of quality. Practices moving into the OMH process will need to be comfortable with the concept of constantly demonstrating value and quality in a quantifiable manner, and to have the reporting capability to back that up.
The 5 Domains of the Oncology Medical Home Model
The OMH model under development by the CoC and COA covers 5 distinct domains that have identified infrastructure and process standards, and are still evolving. Although many elements may appear to be functions that practices already provide, upon deeper review, the pilot practices have learned that these 5 domains are quite complicated.
Patient engagement
This domain focuses on patient access to financial counselors, medical information, and patient portals. Many practices do make these available, but the successful OMH pilot practices realized that they needed to actually track the utilization and success of the levels of patient engagement. The practices that measured how well they were doing by month, by quarter, by physician, and those that identified where they were, where they are, and where they want to be in terms of quantifiable measures found that this was a new way for them to review patient engagement.
Expanded access
This domain focuses on the function of patient navigation, the removal of barriers to access, which could be open hours, after-hours accessibility, education, and enforcement of utilization of the access option. Again, the difference in an OMH-focused practice was not the hours themselves or the policies, but the monitoring, tracking, and continuous attention to barriers, and the removal of those barriers for patients and their access to care.
Evidence-based medicine
In this domain, expectations are set for the use of evidence-based treatment guidelines and clinical trials. The implementation of the guidelines referenced in this domain is driven by the monitoring and tracking of actual use of those guidelines at the point of medical decision-making. Many practices state that their care is evidence-based, but an OMH practice will ensure that they have the technology systems to track and report their compliance on a patient or population basis. An OMH practice will not only track concordance and adherence of medical decision-making to evidence, but also connect the dots to patient performance, length of treatment, incidence of symptoms, and side effects.
Comprehensive team-based care
This domain sets up the structure and expectations for communications and relationships with outside providers, the internal care team, and the patient. Key elements of this communication for an OMH practice include a complete treatment plan and survivorship and end-of-life care plans. The difference for OMH practices from traditional oncology practices is that they will focus not only on the provision and presence of these elements, but on the documentation and tracking of the successes and gaps for continuous quality improvement as well. Mr Gamble also mentioned the importance of including employers and building relationships with them.
Quality improvement
This last domain provides the backbone of the OMH, because without constant measures and monitoring the OMH cannot function. The core elements of this domain include a certified EHR, practice standards for continual documentation and assessment, and an OMH patient satisfaction survey. The COA patient satisfaction survey has grown and is now providing benchmarked data comparisons across physicians, practices, and even similar Medicare populations.
Transitioning to the Oncology Medical Home Model
The most important aspect of the cultural transition to the OMH model, besides the patient focus, is a new emphasis on measurement and continuous assessment. Many of the care elements are present in current patient care, but we do not yet maximize our opportunities for coordination, filling in gaps in communication and education, and thinking outside of the care we deliver directly into what happens to and for our patients between visits, and in other care facilities. An OMH-focused practice considered the entire continuum of care.
This is not an easy process; even the practices that have piloted OMH models have noted that they are wrestling with the implementation, the creation of new teamwork, and a new focus on collaboration. The practices that participated in the pilot OMH process commented that they found great value in the peer-to-peer discussions and the benchmarking and feedback offering insights on their existing processes.
Currently, the CoC is reviewing the domains and the standards, the OMH accreditation process for the 10 pilot practices, and developing the final aspects of the OMH accreditation program. The goal is to accredit 50 other practices in 2016.
Hopefully there will also be a chance to integrate the program with specific payer groups as it continues to unfold. Practices that are interested in the OMH program and process can find more information at the COA OMH website (www.medical homeoncology.org).