Survivorship Care: Building a Program From Obstacles to Opportunities Alicia Rosales LCSW, OSW-C Survivorship Program Manager St. Luke s Mountain States Tumor Institute Boise, Idaho
Reviewing the Standard Standard 3.3 Survivorship Care Plan The cancer committee develops and implements a process to disseminate a treatment summary and follow-up plan to patients who have completed cancer treatment. The process is monitored and evaluated annually by the cancer committee.
Reviewing the Standard Definition and Requirements SCP is a record of the treatment provided, recommendations for follow-up care, surveillance and information about long term and late effects ASCO defined the minimum data elements to be included Process Requirements Cancer committee must have SCP policy and procedure with processes to ensure SCP are delivered to patients with stage I, II, and III disease who complete active therapy with curative intent
Reviewing the Standard Process Requirements Cancer committee must have SCP policy and procedure with processes to ensure SCP are delivered to patients with stage I, II, and III disease who complete active therapy with curative intent SCP must be delivered no later than 6 months after therapy is completed (18 months from diagnosis for patients on long term therapy) Centers may choose to deliver care plans to stage 0 and IV patients but it is not a requirement (These patients may be included in reporting) SCP document can be provided by: physicians, nurses, advanced practice providers, and credentialed clinical navigators SCP must be given in the context of a clinical discussion with the patient in person
Reviewing the Standard Implementation schedule extended Jan 1, 2015 Dec 31, 2015: provide SCP to > 10% of eligible patients who have completed treatment. By the end of 2016: provide SCP to > 25% of eligible patients who have completed treatment. By the end of 2017: provide SCP to > 50% of eligible patients who have completed treatment. By the end of 2018: provide SCP to > 75% of eligible patients who have completed treatment.
Continuum of Care Standard 3.3 Survivorship Care Plans
Overcoming Challenges Focus the survivorship ambition Engage the care team Streamline treatment summaries and care plans Activate Patients Program Evaluation and Reporting
Determining Focus The Advisory Board Company Oncology Round Table: The Survivorship Challenge 2014
Determining Focus Institutional Alignment Staff to do the work Advance Practice Nurses Support Staff Medical Records EHR/EMR
Engage the Care Team The Advisory Board Company Oncology Round Table: The Survivorship Challenge 2014
Engage the Care Team Oncologists PCPs Staff Schedulers Nursing Support Staff Administration Billing/Coding
Engage the Care Team Primary Care Physician Feedback Communication Relevant information Clear roles and responsibilities
Engage the Care Team
Streamline Care Plans The Advisory Board Company Oncology Round Table: The Survivorship Challenge 2014
TEMPLATE COST DATA ENTRY ADDITIONAL INFORMATION ASCO Free Manual LIVESTRONG Free Manual Journey Forward Integrated Software Free $$$$ Purchase License Manual Automated Templates available in Word or Excel Seeking to automate via interoperability standards Available on ASCO s website Can be completed by patients or providers; Spanish available Lengthy patient summary Web-based program Currently assessing the potential for automation Available on LIVESTRONG s website Downloadable program Capable of auto-population through use of CNExT registry s survivorship interface Available on Journey Forward s website Requires considerable initial investment May or may not interface with HER Reporting out data is higher Homegrown Upfront staff investment Potential for full or partial automation Ability to partially or fully integrate with system requirements Capabilities depend on existing IT resources Opportunity to leverage either EHR1 information or registry database
Streamline Care Plans
Streamline Care Plans More than a Treatment Summary!!! What About.? I can t think any more
Activate Patients At MSTI Introduced as part of larger Supportive Oncology Services Displayed in patient rooms Survivorship Brochure Given when patients are scheduled for survivorship appointment
Identifying Patients Ensuring Referral Identifying patients at the end of treatment can be difficult What is already in place to mark the end of treatment? Consider identifying the patient as they begin treatment for curative intent Replace the first 3 month follow-up with survivorship in an automated way
When is the Right Time? Identify the teachable moment within 6 months of treatment
Survivorship Program Evaluation At MSTI Patient Satisfaction Provider Satisfaction Performance Improvement process to track and review patients who complete therapy Reporting for the Commission on Cancer Cost /Reimbursement Analysis
Patient Satisfaction 2011 Survivorship Navigator reviewed documentation from 118 survivorship appointments Surveyed 50 patients by phone
Addressing the Survivors Needs 40% 30% 20% 10% 0% Weight / Physical Activity Fatigue Sexuality/Bod y Image Anxiety Caregiver/ Family Stress Depression Breast Cancer Pilot at MSTI 2012
Addressing the Survivors Concerns Breast Cancer Pilot at MSTI 2012
Provider Input Oncologists continue to have limited buy-in despite high patient satisfaction Looking for additional outcomes Primary Care Physicians Still feel out of the loop Want the care plan to be more accessible and directive for their role Advanced Practice Providers Mixed input with about 75% very supportive of the current model and 25% who feel it is below their licensure and could be done by RN staff
Ensuring Care Plan Delivery
Performance Improvement Custom Crystal report is generated monthly to identify patients who have completed radiation and those who have completed chemotherapy with curative intent. Report is sent to the PI team in each clinic to review patient charts and ensure patient is scheduled for survivorship Report tracks metrics for diagnosis, treatment dates, physicians, date care plan is due, date care plan is delivered, method of delivery (in person or mailed)
Performance Improvement Data
MSTI Program Metrics
Reporting for CoC 2015 Survivorship Care Plans 1602 Percent of eligible patients who received a care plan o 42% (delivered in person and by mail) o 30% (in person only declined subtracted from denominator) 675 404 269 Analytic Cases Completed Total Care Plans Delivered In Person Mailed
Cost and Reimbursement Analysis Look for a model where the revenue offsets the cost High investment of resources should be offset by revenue from billing Can you track downstream revenue from referrals, keeping patients in the healthcare system? Is there a reduction in triage or ED utilization if we keep cancer survivors healthy through the intervention of quality survivorship care? Is there a decrease in outmigration of patients when patients feel cared for?
Cost and Reimbursement Analysis Total Cost per Patient Billed Amount Reimbursed Amount
Cost and Reimbursement Challenges 15% decrease in Billed Amount 27% decrease in Reimbursement 8.5 % increase in Cost (calculated at 2% per year)
Charge Distribution PROFESSIONAL FEE No Charge 99212 99213 99214 99215 FACILITY FEE level 1 level 2 level 3 level 4 level 5 14% 29% 14% 13% 4% 26% 42% 14% 1% 43%
Financial Analysis for Return on Investment $200.00 $180.00 $160.00 $140.00 $120.00 $100.00 $80.00 $60.00 $40.00 $20.00 $0.00 55% 39% 38% 22% 59% 55% 70% 72% 2011 2015
Extend the Conversation To Primary Care Are you ensuring that the primary care physician has a copy of the care plan Does the primary care physician KNOW they have a copy of the care plan Does the primary care physician understand which labs, scans, screening recommendations are the oncologist s responsibility and which remain with the PCP? To the community Does your survivorship program include information about what other services are available to patients in the community?