Category Archives: Uncategorized

Enhancing the Value Proposition: Embedding Palliative Care Services in the Oncology Setting

By Susan van der Sommen, MHA, CMPE, FACHE

nurse and patient holding hands 2In a feature article in the January/February edition of Oncology Issues, Patsy Astarita, LCSW-C, OSW-C, and Michelle Abramowski, MSN, CRNP, share how the Kaufman Cancer Center in north central Maryland developed a palliative care program from the inside out. Though the existing infrastructure of the Kaufman Cancer Center included some palliative care resources, their challenges in developing the program were similar to those faced by other cancer programs: a dearth of existing funding, a navigation program focused on newly diagnosed patients rather than those at the end of life, and limited outpatient palliative care resources, among others.

Despite these challenges, the interdisciplinary care team at Kaufman Cancer Center garnered the requisite leadership support, performed a literature search of evidence-based best practices, and, building upon their existing resources, developed a palliative care program that has met its stated goals: reducing hospital use of chemotherapy at the end of life, while increasing early referrals to hospice and advance care planning. In 2016 Kaufman Cancer Center was recognized with an ACCC Innovator Award for their forward-thinking efforts expanding access to palliative care.

Often confused with hospice (utilized for end-of-life care), palliative care services are intended to provide a patient-centered approach to anticipating—and  thus reducing—pain and suffering, while improving quality of life by addressing the physical, social, emotional, and spiritual needs of the patient and family. According to a study performed by the American Society of Clinical Oncology (ASCO) Ad Hoc Palliative Care Expert Panel, patients with advanced cancer should receive “dedicated palliative care services” within eight weeks of diagnosis, offered concurrently with active treatment. The same study suggests that palliative care services offered early in the treatment process promote clarification of treatment goals, assistance with medical decision-making, enhanced care coordination, and a reduction in stress for the patient, family, and caregivers. Another benefit of introducing palliative care services early in the treatment process is cost reduction and savings through reduced hospital readmissions and emergency room use in the last 30 days of life.

To streamline their processes, the team at Kaufman Cancer Center developed a palliative care screening tool very similar to the psychosocial distress screening tool that has become familiar to most cancer programs in the United States. The five-question palliative care screening tool, now embedded in their EHR, has a 13-point scale that assists the care team in determining if the patient is appropriate for a palliative care referral. Embedding these services into their workflow is further enhanced by a weekly Palliative Care Conference during which team members discuss and review cases to determine next steps for patients and their family and caregivers. Also included in their ongoing programmatic development is a resiliency program to help support their staff as they work with patients during vulnerable times in their lives.

When working to initiate or expand palliative care services in the outpatient setting, most cancer programs face a host of challenges: lack of resources and/or budget; multiple, and sometimes conflicting, priorities; disparate and often disconnected programs. Despite these challenges, the team at the Kaufman Cancer Center did what cancer programs do best: put the patient at the center of their planning processes and developed a program that has improved care and satisfaction while reducing costs.


Contributing blogger Susan van der Sommen, MHA, CMPE, FACHE, is Executive Director, DSRIP, Bassett Healthcare Network, and Chair of the ACCC Editorial Committee.

Learn more about the ACCC Innovator Awards program here.

How Navigation Can Help in Decreasing Readmission Rates and ER Visits

By Tricia Strusowski MS, RN

Patient Navigation Healthcare CompassFACT #1: The last place that cancer patients and their family want to be is in the hospital. Hospital stays also increase the chances of hospital-acquired infections, which can result in a longer length of stay and complications.

FACT #2: Patients and family members do not feel well equipped upon discharge from the hospital, especially when it comes to how to handle procedures at home such as dressing changes, central lines, injections, and drains, just to name a few. Medications can also be very confusing, in particular when there have been changes—adding or removing medications, and/or dosage changes.

How can a nurse navigator help? Let’s start by reviewing the roles and responsibilities of the navigator, which often encompass the following:

  • Coordinate the care of the patient and family from pre-diagnosis through survivorship or end-of-life services, removing barriers across the continuum
  • Provide education and access to clinical trials, utilizing proper health literacy techniques
  • Improve patient outcomes through education, psychosocial support, and performance improvement monitoring
  • Collaborate and facilitate communication between patients, family members/ caregivers,
    and the healthcare team
  • Coordinate care across the continuum with the healthcare team
  • Provide cancer program and community resources, and follow-up
  • Participate in multidisciplinary clinics, tumor conferences, and cancer committee, functioning in the role of patient and family advocate

Given these responsibilities, how can nurse navigators help keep our patients out of the hospital?
First, we need to listen to our patients and their caregivers, and we need to share their story with the entire healthcare team. What are their specific concerns and educational needs? Keep in mind that these may have little or nothing to do with their diagnosis or plan of care. A comprehensive assessment of needs is essential for patients and caregivers to become empowered and successful during cancer treatment and to prevent avoidable admissions and ER visits.

Here are helpful tips for navigators to understand and meet these needs:

Patient and Caregiver Education

  • Discuss the preferred learning style of the patient and caregiver during the intake process
  • Create a disease-site-specific patient appointment checklist that includes information on why their appointments are important
  • Use decision-aid tools to empower the patient and caregiver with the appropriate questions to ask their providers and healthcare team
  • Proactively screen your patients for specific support service needs, e.g., dietitian, social worker, etc.
  • Provide safety tips for the home environment or have a home assessment completed
  • Use the same educational materials across the care continuum to decrease confusion for the patient and family
  • Teach patients/caregivers about reportable side effects and adverse reactions and when to call the physician
  • Provide support, resources and guidance for the caregiver as well as the patient
  • Increase contacts/calls with high-risk patients, our “frequent flyers”
  • Use home care resources to educate patients and their family on new procedures or information on their diagnosis and treatment as outlined by their provider
  • Provide community resources for the elderly and disparate population to set them up to succeed at home, e.g., Meals on Wheels, transportation services, child/elder care, etc.

 Clinician Education

  • Provide staff with health literacy training including “teach back” methods for educating patients (for example, the “Ask, Tell, Ask” method outlined in the Institute of Medicine report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis)
  • Provide medication reconciliation list/guidance and have patients explain their medications and fill their medication planner
  • Incorporate morning reports for the support staff to proactively identify patient needs and the need for phone calls to patients from the appropriate disciplines
  • Initiate early referrals to palliative care for education and symptom management
  • Initiate early goals of care and advance directives discussions
  • Incorporate rounding with inpatient multidisciplinary staff to discuss discharge disposition, barriers to care, length of stay (LOS), discharge delays, carve-out days, and follow-up calls for 24-48 hours after discharge
  • Monitor the patient’s treatment based on national standards and guidelines
  • Create disease-site standing order sets, physician profiles, pathways, and guidelines with timelines when appropriate
  • Research opportunities for creating an oncology medical home or oncology ER/urgent care triage process with protocols
  • Develop plan for avoidable ER visits, i.e., constipation, nausea/vomiting/diarrhea, pain and symptom management, etc.
  • Provide assistance with depression screening (beyond NCCN psychosocial distress screening)

To measure progress, what reports and metrics would be helpful?

  • Request 30-, 60-, 90-day readmission report with reason for admission/chief complaint
  • Request ER visit report for chief complaint
  • Monitor timeliness of appointments, tests, and procedures
  • Review with patients reasons for any missed appointment and assist in resolving issues
  • Create performance improvement projects and metrics to support decreasing readmissions and avoidable ER visits

Discuss and prioritize these ideas with your multidisciplinary team and watch your avoidable admissions and ER visits decline.

Of note: Many of the above examples also align perfectly with the Oncology Care Model (OCM) practice redesign approach, value-based cancer care, and oncology medical home initiatives. Partner with your navigator as healthcare transitions to patient-centered, value-based delivery models.


Contributing blogger ACCC Member Tricia Strusowski, MS, RN, is a consultant with Oncology Solutions, LLC.

Why It’s Important to Carefully Examine Your Practice’s 2015 PQRS and QRUR Reports

by Brittney Fairman, Policy Analyst, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoOn September 26, 2016, the Centers for Medicare and Medicaid Services (CMS) made available the 2015 Physician Quality Reporting System (PQRS) Feedback Reports and the 2015 Annual Quality and Resource Use Reports (QRURs) for every group practice and solo practitioner nationwide. The reports identify providers by their Medicare-enrolled Taxpayer Identification Number (TIN), and reflect who satisfactorily reported data on quality measures under PQRS and, in the QRURs, how physicians performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier. Importantly, these reports will determine whether a practice or solo practitioner will receive a bonus or negative payment adjustment in 2017.

In 2017, those who fail to meet the 2015 PQRS reporting requirements may be subject to a penalty of up to two percent, and practices may face a Value Modifier penalty of up to four percent when performance is compared to national quality and cost performance.

ACCC  encourages members to carefully examine these reports, particularly for inaccuracies, and contact CMS with any questions or concerns about perceived discrepancies. The window to request an informal review is September 26 – November 30, 2016. These reports are not automatically distributed, but must be accessed by authorized representatives from the CMS Enterprise Portal using an Enterprise Identity Data Management (EIDM) account established with CMS.

Reviewing these reports is particularly important in the context of new requirements under the Quality Payment Program (QPP) which will determine reimbursement based on similar measures starting in 2019.

If you are having trouble getting an adequate response from CMS after having contacted them about inadequacies in your PQRS or QRUR Report, please contact  Brittney Fairman at bfairman@accc-cancer.org.


For questions about the 2015 Annual QRUR, 2017 Value Modifier or how to request an Informal Review, contact the Physician Value Help Desk: Monday – Friday, 8:00 AM – 8:00 PM EST             Phone: 1-888-734-6433 (option 3);  Email: pyhelpdesk@cms.hhs.gov

For PQRS and EIDM questions, contact the QualityNet Help Desk:                                       Monday – Friday, 8:00 AM – 8:00 PM EST;  Phone: 1-866-288-8912 (TTY 1-877-715-6222);           Email: qnetsupport@hcqis.org

 

The Power of Sharing Your Story

One in an occasional blog series on topics from Oncology Issues, the journal of the Association of Community Cancer Centers.

By Susan van der Sommen, MHA, CMPE, FACHE, ACCC Editorial Committee Chair

Talking heads At the upcoming ACCC 33rd National Oncology Conference October 19-21, in St. Louis, Missouri, the 2016 ACCC Innovator Award winners will be showcasing their pioneering efforts aimed at improving the provision of care to cancer patients with initiatives that can be replicated in other community cancer programs.

Spreading the Word

In addition to speaking at the National Oncology Conference, every ACCC Innovator Award winner has the unique opportunity to write a feature article for Oncology Issues, ACCC’s bi-monthly journal.  The just-released July/August 2016 issue presents in-depth, “how we did it” articles from several of the 2015 Innovator Award winning programs. But opportunities for ACCC members to share their cancer program’s initiatives and successes are not limited to Innovator Award winners. Oncology Issues features insightful articles from ACCC member programs throughout the country – large and small. And every issue includes a “Spotlight” article profiling an ACCC Cancer Program member.

For instance, in the January/February 2016 issue, authors from two ACCC Cancer Program member institutions wrote about how to “Unlock the Potential of the Cancer Registrar,” describing the integral role their cancer registrars are playing in their organizations’ lung screening programs. And the May/June 2016 issue featured an article from ACCC Cancer Program Member The Valley Hospital’s Blumenthal Cancer Center on its Oncology Nursing Fellowship Program. In feature articles such as these, ACCC members share their real-world strategies for overcoming challenges and improving oncology care delivery, enriching the oncology community as a whole.

What better way to feature your cancer program’s success than through an article or profile published in a journal with national coverage? Many of our colleagues have used the opportunity to garner local media coverage in their respective markets; others have showcased their work among their peer group – which sometimes includes much larger centers.

In a recent ACCC Communications Survey, ACCC members were polled on the association’s journal, Oncology Issues:

  • 90% said that Oncology Issues is the “primary benefit of ACCC membership.”
  • 98% said that Oncology Issues “contains practical information, insights, ideas, and tools.”
  • 92% said that Oncology Issues “contains information that I do not find in other sources.”
  • 88% said that Oncology Issues “helps my cancer program stay ahead of the competition.”
  • 88% said that Oncology Issues is “must reading for me to stay ahead in my profession.”

What makes the Oncology Issues so successful? Input from ACCC cancer program members like you! To help spread the word to ACCC members about opportunities to contribute to the journal and how Oncology Issues’ content can be leveraged to benefit your program, this year’s National Oncology Conference will feature a new agenda item – “Oncology Issues Live!” hosted by members of ACCC’s Editorial Committee. Interesting in learning more about contributing or having your program featured in Oncology Issues? Want to be part of the Editorial Committee? Come to “Oncology Issues Live!” at the ACCC 33rd National Oncology Conference, October 19-21 in St. Louis, and connect with us.

 

Snapshot of a Case-Based Financial Advocacy Network Workshop

By Joseph Kim, MD, MPH, MBA

Hands-creating-circle-of-supportACCC recently held its first Financial Advocacy Network (FAN) Case-Based Workshop of 2016.  Attendees representing a wide range of professionals working in financial advocacy joined in lively discussions across the continuum of cancer care in the community. Even today, many cancer programs do not have enough dedicated financial advocates providing support and assistance to cancer patients who struggle to pay for their care. As a result, social workers continue to shoulder the bulk of the responsibility of identifying financial resources and assisting patients with the process of completing online applications and forms for patient assistance programs.

Solving Real-World Scenarios

At the May 23 workshop held in Cleveland, Ohio, participants jumped right into dynamic case-based discussions, drilling down into specific scenarios that required them to uncover clues and develop customized plans for patients based on the unique circumstances presented case by case. Throughout the day, several key themes emerged:

Medicare:  Discussions touched on improving health insurance coverage for patients who are on Medicare. There is clear need to educate both providers and patients about the complexity of Medicare and the different options that range from Medicare Advantage, Medicare Supplement (Medigap), Medicare Select, Medicare Savings Program, Medicare Low Income Subsidy (Extra Help), and much more. Some cancer programs hold dedicated education and outreach events around the Medicare Open Enrollment Period so that patients understand their options.

Improving Communication: Another issue that resonated with most attendees was the need to improve communication about patients’ financial concerns across all the members of the cancer care team. Since this information is often not clearly documented in the patient’s chart, it may be difficult for nurses, and medical oncologists to truly understand the total impact the costs of treatment may have on a patient’s life. Improving those lines of communication could lead to creative and innovative ways to reduce the financial burden placed on cancer patients.

Tracking Savings: Almost every cancer program helps patients find various drug assistance programs, but many may not be effectively tracking their savings across their entire financial advocacy department. Attendees remarked how they were using manual spreadsheets to record the direct amounts received from patient assistance programs, drug replacements, and donations from foundations and other charitable organizations. Some track how their hospital-based charity programs are helping cancer patients with their costs of treatments. There are also savings that can be measured when financial advocates help patients improve their insurance coverage options, but these savings are not frequently being tracked.

Growing Need for Financial Advocacy: Throughout the workshop, attendees agreed on the need to strengthen and grow their financial advocacy programs. The complexity of cancer care is rising and the out-of-pocket costs are becoming significant burdens that may impact how patients receive care.

If you missed the FAN Workshop in Cleveland, be sure to mark your calendars for the upcoming FAN Workshops in Dallas, Texas, on August 17, 2016, and in Philadelphia, Pennsylvania, on September 29, 2016. Learn more and register here.

In the meantime, check out the resources available to financial advocates on the ACCC Financial Advocacy Network section of the ACCC website.

_______________________________________________________

Guest blogger Joe Kim, MD, MPH, MBA, is serving as the facilitator for the 2016 ACCC FAN Case-Based Workshops.  Dr. Kim is President of Xaf Solutions.

 

 

 

ACCC Voices Part B Demo Concerns on Capitol Hill & at CMS

By Amanda Patton, ACCC, Communications

ACCC-PartB-Demo-Meeting-Capitol Hill-crop2With the Medicare Part B Drug Payment Model comment deadline fast approaching (Monday, May 9 at 5:00 pm EDT), ACCC continued its push to educate policymakers on the detrimental impact this ill-conceived proposal will have on community cancer care, providers, and patients.

This morning ACCC President Jennie R. Crews, MD, MMM, FACP;  ACCC Past President Ernest Anderson Jr., MS, RPh, FASHP; and Leah Ralph, Director of Health Policy, ACCC; together with representatives from the Hematology/Oncology Pharmacy Association (HOPA) and the Oncology Nursing Society (ONS), traveled to Capitol Hill to meet with Senate Finance Committee staff and discuss concerns about the Part B proposal’s impact on cancer care. During the meeting, ACCC shared information from a data analysis that reveals the significant financial impact the proposal would have on providers and patients.

In a meeting with CMS Center for Medicare and Medicaid Innovation (CMMI) staff on Monday afternoon, ACCC leadership, along with representatives from HOPA, and ONS—reflected the voice of multidisciplinary cancer care providers.  ACCC shared results from the Part B proposal data analysis and reiterated ACCC’s strong concerns that are reflected in our comment letter to the agency.  Read our comment letter.

Stay tuned for advocacy updates from ACCC.

 

Proposed 2016 Medicare Rules

By Leah Ralph, Manager, Provider Economics and Public Policy, ACCC

Centers_for_Medicare_and_Medicaid_Services_logoThe Centers for Medicare & Medicaid Services (CMS) 2016 proposed rules are out, and, not surprisingly, we continue to see the agency push outpatient payments toward more bundled services and move full steam ahead to tie Medicare payments at large to quality and value in the coming year.

2016 HOPPS Proposed Rule

Generally speaking, the proposed Hospital Outpatient Prospective Payment System (OPPS) rule includes few surprises, most notably CMS is proposing a -2% across-the-board reduction to compensate for “excessive” packaged payments for laboratory services in CY14. The rule also includes nine new comprehensive ambulatory payment classifications (C-APCs) to add to the 25 introduced last year and proposes consolidation and restructuring of nine APC clinical families. Importantly, CMS will continue to reimburse drugs at ASP+6% in the hospital outpatient department. The agency also provides some flexibility on the “two-midnight” rule. Currently the rule requires that a beneficiary to remain in the hospital for longer than two midnights in order for the stay to be reimbursed as an inpatient stay. Under the proposed rule, CMS would recognize some shorter stays as inpatient, and would evaluate on a “case-by-case” basis.

 2016 PFS Proposed Rule

The proposed Physician Fee Schedule (PFS) rule was released later than expected this year, perhaps due to slightly more contentious provisions. The good news – perhaps – is that, as proposed, the 2016 PFS would have no (0%) impact on Medicare payments in hematology/oncology. However, on the radiation oncology side the news is not so good. If all of the proposals in the rule are finalized, radiation oncology will face an estimated -3% cut and freestanding radiation therapy centers will see a -9% cut due to a combination of new code values and a change in assumption involving the overall use of linear accelerators. CMS also indicates how it will treat biosimilars for the purposes of Part B reimbursement, proposing to assign the same HCPCS code to all biosimilars that reference the same innovator drug. These would be paid based on their volume-weighted ASP+6% of the reference product’s ASP. If no ASP data is available, biosimilars would be reimbursed at 100% of their wholesale acquisition cost.

Under the PFS, CMS also proposes to create two new CPT codes for advanced care planning services, one to start the conversation with a patient and the other for continued discussion. The rule also begins the phasing out of the PQRS (the 2018 payment adjustment will be the last); adjustments for quality reporting will now be made under the new Merit-Based Incentive Program (MIPS), created by the legislation that repealed the Medicare Sustainable Growth Rate (SGR). CMS seeks comments on MIPS on issues like the definition of clinical practice improvement activities, how to define a physician-focused payment model, and more.

ACCC will be submitting comments on both rules, due August 31 and September 8, respectively. On Tuesday, July 21, 4:00-5:00 PM EST, ACCC is hosting a members-only conference call with a full rundown of both proposed rules. Stayed tuned.