An Optimal Care Coordination Model for Medicaid Patients With Lung Cancer

J Clin Pathways. 2021;7(5):24-25.

In 2016, the Association of Community Cancer Centers (ACCC) embarked on a 3-year, multiphase initiative to design, test, and refine an Optimal Care Coordination Model (the Model) for Medicaid patients diagnosed with lung cancer.^1-3 The Model’s goal: to help cancer programs identify and reduce health disparities between Medicaid and non-Medicaid patients through assessments that facilitate and expand access to appropriate multidisciplinary coordinated care. The Model was designed to be a patient-focused framework for cancer programs to evaluate care coordination for lung cancer and plan quality improvements and is composed of 12 interrelated assessment areas:

1. Patient entry into lung cancer program addresses factors such as referral sources, referral processes, and timely access to appropriate care.

2. Multidisciplinary treatment planning addresses factors such as patient evaluation and treatment planning and recommendations provided by a range of health care providers.

3. Clinical trials address factors related to overcoming cultural, financial, and logistical barriers encountered by patients in accessing clinical trials.

4. Supportive care addresses factors related to the evaluation of physical, emotional, mental, and spiritual symptoms and the infrastructure and resources available in the cancer program to manage these symptoms across the continuum of care.

5. Survivorship care addresses factors related to the ongoing surveillance for recurrence of primary cancer, prevention and early detection of new health problems, management of latent and long-term toxicities associated with cancer treatments, and overall patient wellness across the continuum of care.

6. Financial, transportation, and housing needs addresses factors related to the financial barriers to care and mechanisms to identify and eliminate such barriers.

7. Tobacco education addresses factors related to the evaluation of tobacco use and provision of tobacco education, including cessation strategies for patients with lung cancer.

8. Navigation addresses factors related to the identification of patient needs and barriers to care and strategies to minimize gaps in service among vulnerable and underserved groups.

9. Treatment team integration addresses the depth, breadth, and effectiveness of team collaboration through the care continuum.

10. Physician engagement addresses factors related to disease expertise, availability to the patient and care team, effectiveness in team science and communication, and leadership roles. 

11. Electronic health records (EHRs) and patient access to information addresses factors related to the facilitation of interdisciplinary communication along the continuum of care through the capacity to access clinical information from physician practices, hospitals, outpatient clinics, and diagnostic centers through optimized EHR platforms. 

12. Quality measurement and improvement addresses factors related to quality metrics that can reveal potential disparities in coverage type, socioeconomic status, gender, race, and ethnicity and help monitor these to ensure minimal variation in patient outcomes.

Each of these 12 interrelated assessment areas are mapped into five levels, from Level 1 (fragmented care and a low focus on optimal care coordination) to Level 5 (optimal care coordination with a patient-centered focus that requires education and engagement with patients and their caregivers to facilitate shared decision-making and increased participation). Progress to a higher level of care coordination implies that all conditions for the lower level(s) of care coordination continue to be met. Depending on the assessment area and contextual factors, achieving Level 5 may be attainable for some cancer programs and aspirational for others. Each assessment area requires the selection of at least one specific and measurable parameter as an evidence-based and institution-specific benchmark for continuous monitoring of quality improvement. 

The Model can be deployed by any cancer program, regardless of size, setting, or resource level, to help identify disparities, strengthen and expand access to optimal lung cancer care, and articulate aspirational goals. The Model is available in its entirety online at accc-cancer.org/care-coordination. Cancer programs should strongly consider taking the online assessment at accc-cancer.org/6-steps to receive a downloadable customized report of their results in each assessment area, as well as a crosswalk to more than 100 quality measures (Image 1). 

References

1. Oyer RA, Lathan CS, Smeltzer MP, Kramar A, Boehmer L, Asfeldt T. An optimal care coordination model for Medicaid patients with lung cancer: rationale, development, and design. Oncol Issues. 2021;36(2):30-35. 

2. Smeltzer MP, Boehmer LM, Kramar A, Asfeldt T, et al. An optimal care coordination model for Medicaid patients with lung cancer: results from beta model testing. Oncol Issues. 2021;36(3):80-94.

3. Oyer RA, Lathan CS, Smeltzer MP, Kramar A, et al. An optimal care coordination model for Medicaid patients with lung cancer: finalization of the model and implications for clinical practice in the U.S. Oncol Issues. 2021;36(4): In press.

4. Improving care coordination, overview. Association of Community Cancer Centers. Accessed May 28, 2021. https://www.accc-cancer.org/projects/improving-care-coordination/overview