The OCM Has Been Challenging, But Effective

Alti Rahman, MHA, MBA, CSSBB

There is a lack of hard data on practice performance that makes it difficult to understand where to make improvements so that goals under the Oncology Care Model (OCM) can be reached, 2 administrators told a recent audience of oncology professionals. However, with the information that is available, it is possible to achieve positive changes and even a spirit of friendly competition, they said.

“We have seen very meaningful changes,” said Alti Rahman, MHA, MBA, CSSBB, practice administrator for Oncology Consultants of Houston, who described having instituted monthly staff meetings at which CMS data regarding practice performance on OCM quality measures was discussed. Wherever results could be measured it has been possible to make headway. “The areas that we’ve struggled with are the areas that we’ve had difficulty reporting on,” he said.

Rahman shared the podium with Anne Marie Rainey, MSN, RN, CHC, compliance and control officer for the Clearview Cancer Institute of Huntsville, Alabama, at the 2017 Community Oncology Conference for the Community Oncology Alliance. Already, the OCM has injected more clinical value and efficiency into practice activities, Rahman and Rainey agreed. Care has become more patient-centered as their practices have broadened mental health and advanced care initiatives. Interdepartmental communications also have improved, and unnecessary use of hospital and emergency departments (EDs) has been reduced.

Earlier this year, CMS released what practices have described as an extremely useful cache of information about claims data, not just from their own clinics, but from their market area. This has enabled practices to understand much more about what is going on with their patients. Rahman said practices are hungry for more of this data and would like CMS to provide regular installments. “We’ve had an iteration of it, and we need more.”

Despite its usefulness, the mass of data needs to be scrutinized and picked apart carefully to arrive at meaningful insights that could actually point to ways a practice could improve its operations, Rahman said. “Even though you have 10 patients admitted to a certain hospital at a rate of $50,000 each and another hospital has 5 patients at a rate of $500,000, that’s still a very surface-level view.” Rahman’s practice has partnered with analytics companies to help with the job of interpretation.

Reporting data to CMS also has been a challenge for practices. They have had to employ new software and synchronize that with established practice management systems that often “don’t play nice” with other technology, Rainey said. Sometimes a software system will deliver an unexpected benefit, however. For Rainey’s practice, the capabilities of a patient portal system enabled her to review patient lists and spot information gaps that wouldn’t have been acceptable to CMS. “You never know what to expect the first time you go to submit that quality data. It was a really big deal for us, just knowing that that system worked. We were able to validate the data and submit it relatively easily,” she explained.

Better Results on Advanced Care Directives

Administrators at Rainey’s and Rahman’s practices were hesitant to go out and acquire new software management systems to help with the OCM transition. “There was so much change already going on. I cannot imagine starting the OCM and trying to change the system at the same time. That would be very stressful,” Rainey said. It was better to find a “middle ground” between old and new than start out afresh with all-new software, Rahman added.Completion of advanced care directives became a prime target for improvement at Rainey’s clinic. Practice administrators knew already that this element of patient-centered care had been deficient because staff often felt uncomfortable discussing these issues with patients. They also recognized this as an area in which they could make definite and measurable improvements.

Previously, “Only about 1.5% of our patients had a DNR (do not resuscitate) status documented in a structured field in our electronic medical record,” Rainey said. “I’m really proud to say that we now have about 75% to 76% of our Medicare patients consistently documented. That’s just one area where it’s really opened the door for us to have to ask patients about something that maybe is uncomfortable for the staff member.”

As part of this effort, her clinic created handout information to answer patients’ questions about advanced care directives and other end-of-life decisions. The practice has also been screening for depression more actively, with the result that it has identified patients who could benefit from social workers or psychiatrists. They’ve also worked with physicians to make sure these patients’ needs are being addressed. “Had it not been for OCM requiring it, we probably wouldn’t have taken that strong a stance on getting it done,” Rainey said. Because of the need to coordinate the various elements of cancer care more successfully under the OCM, efforts have been made to improve communication between staffers, and this has been done successfully, Rahman said.

“There are so many areas of a practice that need to be managed, from billing and contracting to compliance and clinical operations. It’s created an environment where we have to come together and look at how patients are treated from all those different perspectives.”

Patient Response to OCM Implementation

Rainey agreed that, in her practice, departments that hadn’t worked together very well before have begun coordinating well. “I think that seems to be a huge win for everybody. There has been a higher level of communication.”Patients have demonstrated that they are clearly interested in the OCM and how it is going to affect their care. At Rainey’s practice, a notification letter was sent out to patients to bring them up to speed on the transition and what it signified. They got about 60 phone calls from patients in 2 days, with a lot of questions, mostly about whether patients would still be able to see their accustomed doctor. “Since then, the more they have seen of their care plans, the more they like this,” Rainey said. Patients also like that medical assistants and practitioners are taking more time to explain things to them and reach out where needed.

Striving for Improved Triage

Rahman said that a concern in his practice was that the information needed to explain the OCM would be too “dense” for patients, so they put together an video that would explain things in a way that wouldn’t confuse or overwhelm patients who already were laboring to understand their personal care and cope with the rigors of treatment.Rainey’s practice has studied phone calls and patient navigation efforts to figure out what could be done to reduce the number of patient hospital stays and ED visits. The clinic found instances where nurses told patients to go directly to the ED. To improve direction, the practice established triage pathways for such conditions as nausea, vomiting, and diarrhea; more are pending. “We’re trying to make some changes based on what we’ve seen, but we’re also hoping to engage with some data analytics companies to pull out a bit more information, because it is a great deal of data,” Rainey said.

Despite the need to reduce unnecessary trips to the ED, Rainey’s practice decided that extending clinic hours would not have made a significant difference. The clinic was already open from 7 AM to 6 PM Monday to Friday, and most ED visits occurred during the regular workweek. “For us, it didn’t make sense to extend the time frame there,” she said. What was really happening was patients were heading for the ED without first calling the clinic to indicate that they weren’t feeling well. To counter this, Rainey’s practice decided to initiate a “call us first” campaign.

Finding Ways to Improve Patient-Centered Care

Rahman’s clinic already had weekend hours, but expanded to after-hours access on weekdays. The clinic made it easier for patients to reach out to providers and made a habit of continuously communicating the availability of staff to overcome the patient perception that after regular clinic hours “their best option for medical attention is an ED.” This information is sent to patients in e-mail notifications and is made available on the practice portal.Rainey said her clinic hopes to establish outpatient palliative care by partnering with a local hospital. Although “that could be potentially really beneficial for our patients, one of the concerns is that the move may worry some of the other providers in their market space. For example, they have a clinic near a hospital, but the palliative care program they want to initiate would be with a competing hospital.

With so much at stake in the process of transitioning to the OCM, practices want to avoid making mistakes that will turn out to be costly. Rahman’s clinic is looking for ways to monitor its progress toward achieving CMS quality goals. Such information could serve as an early warning that a coarse correction is necessary. This would enable an intervention that would avoid a unpleasant surprise at the end of a reporting period.

Build a Network of Support

“The OCM is an opportunity to demonstrate and bring to light all of the things that we’ve known all along about efficiency and quality of care,” Rahman said. “We don’t want to find out toward the end of a measurement period whether we were positive or negative. We’re trying to develop an interim way to track progress to see what we need to do to stay at a positive performance level.”As advice to others involved with the OCM, Rainey recommended involving key stakeholders early in the process to ensure that OCM changes are supported. “That’s huge. There are still many people who don’t understand what this means.” She said good communication and the ability to accept constructive criticism will benefit a practice. “If you incorporate those 2 things, I think you have a really great foundation to make things happen in a way that is really going to be sustainable.”

Rahman recommended that practices have a clear understanding of the benefits they expect to receive from whatever processes they initiate. “If you can’t get data out of it, then you really don’t know the validity of it.” It’s important to anticipate the propensity for staff members to forget and fail to carry out objectives, he added.

An audience member who said she worked for Cigna asked whether physicians in Rainey’s and Rahman’s practices were engaged with the OCM and had changed their styles of practice at all. Rainey responded, “Some are trying to do this right, and others still don’t understand the importance of the change that is taking place, and they’re still practicing how they would have practiced. I think that’s a challenge for us. We have our work cut out from that standpoint.”

Rainey added that monthly performance reviews with physicians at her practice have created a spirit of friendly competition. “They can see that ‘Dr X is 100% on everything, and I’ve got some work to do.’”