A Place Patients with Cancer Can Call Home, Part 1

More than 10 years ago, John D Sprandio, MD, left his role as president of an independent practice association (IPA), frustrated by the organization’s inability to clinically integrate. Back at his practice, he found more of the same. Undaunted, he and his fellow clinicians established goals and began climbing a steep mountain toward offering consistent, high-quality care. 

Along the way, Consultants in Medical Oncology and Hematology (CMOH) became the first National Committee for Quality Assurance (NCQA)–recognized specialty patient-centered medical home (PCMH) and the first oncology medical home.

First Report Managed Care recently sat down with Dr Sprandio, who is CMOH’s chief physician. He told us how his group got started and what they did to overcome early obstacles. He also addressed the role of clinical pathways in a medical home and explained why communication is key. Finally, he provided a few practical examples that illustrate the differences between the oncology medical home model and a typical oncology medical program or practice. 

FRMC: Let’s start with the origins of the CMOH medical home. How did it all begin?

The origins began more than 10 years ago. I was president of a large IPA with 130+ medical oncologists and radiation oncologists at 26 sites, including 2 academic centers. We set a goal to clinically integrate all of our practices by standardizing around clinical guidelines/standards of care, collecting data, and sharing processes and opportunities for improvement. 

I served the group until 2003 but resigned because we could not achieve the goals for clinical integration. As I look back, I see that the failure was in part due to the fact that only a handful of the sites had an electronic medical record (EMR) system, and we did not have standardized clinical pathways. We had chemotherapy guidelines, but, at that time, the clinical pathways concept was still relatively foreign.

FRMC: So what did you do? 

I retreated into my own 10-physician practice, started collecting data, and saw that our 3 sites were not clinically integrated. But we were motivated by the white paper published by Alice Gosfield, JD, and James Reinersten, MD, “Doing well by doing good: improving the business case for quality” (2003; unpublished manuscript). It addresses the barriers in the practice environment that keep physicians from becoming more accountable for quality and cost. The paper outlined five essential recommendations:

• Streamline processes;

• Standardize roles and responsibilities;

• Make physician activity more clinically relevant;

• Engage patients and their families more consistently and more completely; and

• Fix accountability for the execution of care at the locus of control.

We added to these the sixth goal of developing data systems that could enable continuous process improvement.

FRMC: How did that go? 

Initially, we weren’t able to accomplish any of our goals, even though we had obtained and fully implemented an oncology-specific EMR. So we developed a software app on top of our EMR, which allowed us to address all of the goals. The app showed providers, in real time, how they were performing in comparison with their peers. As we added capabilities to our app, we saw a dramatic decrease in emergency room (ER) utilization and a concurrent reduction in hospital admissions for the most vulnerable cohort of our patients in 2009. 

When we reviewed what we had done, we realized that we had exceeded all of the criteria for the NCQA Primary Care PCMH-PPCTM recognition program. So, we applied, and NCQA recognized us in 2010 as the country’s first specialty level III PCMH as well as the first oncology practice PCMH. 

Since then, we have worked with the NCQA in developing the more generic patient-centered specialty practice standards. There are about 150 specialty practices that have been recognized through this program. About 40 of them are medical oncology practices, including our practice.

FRMC: So it sounds as though you did not originally intend to qualify for PCMH status.

That’s right. When we started applying Gosfield and Reinertsen’s principles of transformation, the primary care PCMH standards were not even published yet. We were not intending to qualify for anything. We were inwardly focused on fixing the physician work environment, making care more effective, and developing systems that would help us become more accountable for quality and cost. 

As we were doing this, unbeknownst to us, the primary care PCMH principles were developed in 2008. Once we became aware of the standards, we realized that we exceeded them. This sends a very powerful message.

FRMC: And what is that message?

The message is that the real barrier to improving the consistency, quality, and cost of care resides in fixing the physician work environment. We proved this by addressing the “physician time-stealers” when we created an oncology-specific process, work flows, and supportive technology. We focused on addressing the day-to-day misery that we faced as physicians, and we ended up positively driving the consistency, quality, and cost of cancer care—and qualifying for NCQA recognition. We also started a major movement. 

FRMC: That’s quite impressive. Can you talk about the role of clinical pathways in a PCMH?

PCMH capabilities facilitate adherence to clinical pathways. Both clinical pathways and the medical home model aim to streamline processes, and more consistently meet patient needs.

FRMC: And that must help improve care coordination.

Exactly.

FRMC: Can you give an example? 

With clinical pathways, patients are more likely to have multidisciplinary assessments prior to initiating therapy. So, with breast cancer, for example, that means getting the patient in front of the surgeon, radiation oncologist, and medical oncologist. The order doesn’t matter, but they each need to evaluate the patient and then collaborate on a plan. 

FRMC: That doesn’t happen in conventional settings? 

There are a lot of programs where patients may see only the surgeon. They sometimes don’t see a medical oncologist until after surgery and after high dose radiation therapy is given. A clinical pathway requiring a multimodality collaboration can help to optimize care delivery and coordination.

FRMC: Can you give an example of how care coordination affects treatment? 

Since we initially started taking a more structured, multidisciplinary approach to breast cancer in the 1990s, we have found that, 70% of the time, there are modifications to the treatment plan based on having an open discussion with the entire care team, including the surgical, medical, and radiation oncologists; the pathologist; and the radiologist. Some of the modifications were major; others were minor but meaningful.

This standardized process epitomizes the broader concept of a clinical pathway.