Anne Chiang, MD, PhD, is an associate professor of medicine in the Section of Medical Oncology and the associate cancer center director of Clinical Initiatives at the Yale School of Medicine

Consolidation of community oncology practices with hospital-based cancer centers is an accelerating trend that will affect future healthcare delivery models.

 This year, the Community Oncology Alliance reported hospital acquisitions and corporate mergers among 55% of 1338 community oncology practices surveyed, representing a 20% increase over the previous year’s results.

Primary drivers of this trend include declining physician reimbursements for cancer treatment and care outside the hospital setting, increasing overhead for care delivery, and mounting shortages of medical oncologists available to care for a growing cancer patient population. Hospitals are motivated to acquire physician practices to expand their referral base, optimize payer relationships, and to maintain and/or grow pricing power for medical services.

In keeping with this trend, the Smilow Cancer Hospital at Yale-New Haven acquired two large medical oncology practices operating in 10 discrete community locations. The acquisition, which occurred in 2011-2012, included 23 physicians and more than 150 staff, and Smilow is preparing to integrate additional practices.

Physician practices joining hospital-based programs must comply with federal, state, and accrediting body regulations established to ensure patient safety and care quality. Historically, private office practices have not been responsible for meeting these requirements, and the resulting gap in compliance with national and local patient safety mandates is oftentimes significant.

Customary practices in office settings, such as verbal orders, administration of medications and prescription renewals by unlicensed personnel, and the admixture of hazardous drugs in uncontrolled environments, are not permitted in hospital-based facilities. Patient identification processes are often loose, and targeted patient assessments, such as pain, nutritional status, distress levels, and fall risk, are typically not performed or are undocumented in office practices, whereas these elements are mandatory in hospital-based settings and/or for cancer program accreditation.

Similarly, while patient/family education is commonly delivered in office practices, documentation is often absent or limited. Regulatory noncompliance can result in loss of accreditation and reimbursement for services. Consequently, hospitals must incorporate regulatory compliance in merger agreements and establish clear methodologies for achieving alignment of candidate practices with regulatory body requirements and institutional standards.

Oncology nurses—because of their education, experience, and critical place on the healthcare team&mdash;are ideally suited to evaluate gaps, to design and implement strategies to promote compliance in newly acquired medical practices, and, ultimately, to ensure patient safety and quality care.

The Smilow community oncology integration project engaged 15 institutional teams, each focused on its specific area of expertise (eg, nursing, pharmacy, infection prevention, life safety) and coordinated by a steering committee. The teams participated in preliminary gap analyses, made recommendations for and implemented alignment plans, and conducted interval monitoring—not only to determine degree of compliance but also to reinforce practice changes designed to achieve alignment with institutional standards.

Assessment was accomplished through one-onone interviews and focus groups, onsite observations, and medical record reviews guided by structured instruments. Alignment strategies involved the integration of best practices, including unique telepharmacy technology, novel staff and physician engagement strategies and practice-based educational programming.

To ensure successful transformative practice and process change, transition planning incorporated understanding of restraining and driving forces and incorporated coalition building, targeted staff engagement strategies, consistent and clear communication, focused education, and reinforcement.

More than 50 practice and process changes in seven key areas, including patient safety, medication management, communication, environment of care, operations, infrastructure, and professional development, were implemented during a 7-month post-assessment period.

Top challenges experienced during the early transition phases included: (1) staff and physician resistance to the adoption of a new identity and different processes (especially with multiple changes happening simultaneously); (2) communication pattern disruptions associated with reporting decentralization, and (3) role restructuring to comply with scope of practice mandates. Adding a new discipline (ie, pharmacy) to the team to perform functions that were traditionally a primary nursing role was also difficult. However, with time and experience, these challenges have dissipated somewhat, and nurses have been able to integrate more comprehensive patient assessment and other best practices into their clinical practice repertoire.

At 12 and 18 months post -“Go Live,” process change continues to evolve for the two newly acquired practices as a new electronic medical record unifying all practice sites has been implemented. Going forward, opportunities for performance improvement include increasing clinical trial accrual, provision of supportive care services to identified patient subpopulations, development of electronic reporting of key processes, and communication enhancements.

Transitioning community oncology practices from office- to provider-based structures is a challenging project that offers opportunities for experienced oncology nurses to explore new roles as change champions and transition leaders. At Smilow, the nursing staff—together with their physician counterparts and leadership&mdash;made the network vision a true reality.

			Butcher L. Oncology landscape continues consolidation. 

			Forte GJ, Hanley A, Hagerty K, Kurup A, Neuss MN, Mulvey TM. American Society of Clinical Oncology national census of oncology practices: preliminary report. 

			Community Oncology Alliance. Community Oncology Practice Impact Report: The Changing Landscape of Cancer Care. http://glacialblog. com/userfiles/76/Community_Oncology_Practice_Impact_Report_6-25- 13F(1).pdf. Accessed June 27, 2013.

			Kocher R, Sahni NR. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. 

			Appelbaum SH, Habashy S, Malo JL, Shafiq H. Back to the future: revisiting Kotter’s 1996 change model. 

Articles

Consolidation of community oncology practices with hospital-based cancer centers is an accelerating trend that will affect future healthcare delivery models. This year, the Community Oncology Alliance reported hospital acquisitions and corporate mergers among 55% of 1338 community oncology practices surveyed, representing a 20% increase over the previous year's results.

Anne Chiang, MD

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