Medication care plan examples
The Center for Medicare and Medicaid Innovation Oncology Care Model (OCM) aims to facilitate the transformation of oncology practices to deliver efficient, high-quality health care. The requirements for participation within the OCM are substantial, including the commitment to incorporate key aspects of high-quality care into their practice.1 Although practices may be tempted to find workaround solutions that “check the box,” the real opportunity exists for practices that embrace the spirit of the OCM and view the implementation of requirements as a means to transform the practice to improve care. Unlike other initiatives, OCM is unique in the provision of financial support for practice transformation. Practices receive up-front monthly Enhanced Oncology Services payments of $160 per month per 6-month episode of care for patients receiving medical treatment for cancer.1,2 In addition, practices that successfully reduce the total cost of care and improve outcomes for beneficiaries will be eligible to receive performance-based payments. This financial support is critical to overcoming barriers to meeting requirements related to lack of resources, which are reported by practices implementing the Commission on Cancer’s requirements of distress screening and survivorship care plans.3-5
The University of Alabama at Birmingham (UAB) and the University of South Alabama Mitchell Cancer Institute (MCI) identified the provision of treatment plans consistent with recommendations of the Institute of Medicine to be the most challenging OCM requirement.1,2,6 Treatment plans and survivorship care plans are lay language documents that the oncology team provides to patients, caregivers, and other healthcare providers that summarize the patient’s diagnosis, treatments, potential adverse effects, care team, psychosocial and supportive care, practical concerns, and advance care directives.6 Treatment plans are provided when patients start treatment, and survivorship care plans are provided when patients transition from active treatment to a surveillance period.
Although this transformation is ongoing, several important lessons have been gleaned from early implementation. First, be realistic about institutional resources and find partners for collaboration. Both UAB and MCI struggled to provide survivorship care plans to patients. Creating survivorship plans was time-consuming and required frequent updating of content. The clinician champions for survivorship care planning did not have the capacity to develop content for up-front treatment plans within the time frame required by the Center for Medicare and Medicaid Innovation. Therefore, the institutions needed to outsource to build this capacity. They partnered with Carevive (Miami, FL), whose care planning system combines electronically captured patient-reported outcomes and clinical data, and then processes the data through an algorithm-driven rules engine to generate a patient-specific treatment plan or survivorship care plan. This approach not only meets reporting requirements and incorporates patient-reported outcomes, but also can serve as a practice transformation tool as a result of the interdisciplinary nature of implementing treatment plans across surgical oncology, radiation oncology, and medical oncology disciplines.
Second, start small. In preparation for OCM, UAB and MCI engaged in a pilot study that tested up-front treatment plans for patients with early-stage breast cancer. The choice of breast cancer for the initial pilot capitalized on physician champions. The pilot evaluated performance on ASCO Quality Oncology Practice Initiative quality measures. This study demonstrated that treatment planning was not only feasible but also improved performance on specific quality measures associated with accreditation programs, such as addressing pain and emotional distress. In addition, the pilot allowed for clinician and staff feedback. The clinicians requested a dashboard that would highlight patient-reported outcomes and specific patient recommendations within the treatment plan. On the basis of this feedback, a dashboard was incorporated into the care planning system before widespread adoption.
Third, engage stakeholders early. Although the pilot study introduced treatment planning to the breast oncologists, broad implementation affects the workflow of multiple clinical staff members. Each site met with and engaged clinic managers, navigators, social workers, nurses, nurse practitioners, and physicians. These meetings with the clinical teams encouraged team members to consider how to integrate treatment planning into clinic workflow, to identify the right person on the team to create and deliver the care plans, and to determine additional personnel needs. UAB and MCI are able to support salaries for additional personnel using OCM dollars, including nurse practitioners, nurse managers, care coordinators, and navigators. The meetings with the clinical teams also aided in identifying overlap with other ongoing projects or accreditation efforts. For example, we considered how to increase survivorship care plan delivery to meet Commission on Cancer requirements. Meeting multiple requirements within one initiative helped to garner support from new champions for the project. Furthermore, engagement of administration, including the chief financial officer and OCM Steering Committee, was crucial in obtaining the financial support from personnel, infrastructure, and information technology (IT) solutions, such as the Carevive care planning system. The processes for implementation are evolving over time, and we anticipate they will continue to do so as part of the quality improvement process.
Fourth, optimize the use of the electronic medical record (EMR). One of the greatest concerns of the clinical teams was the impact on workflow, specifically related to documentation. In a culture where the physicians complain of “death by clicks” (M. Neuss, personal communication, October 2016), physicians were extremely resistant to logging onto yet another system, only to double document what was already in the EMR. Thus, UAB began the process of IT integration between the care planning system and Cerner (Kansas City, MO), UAB’s EMR platform. For this, UAB identified five key integration components. First, the legal and security teams worked to ensure the security of protected health information, both in terms of data security and user access. The care planning system needed a shared log-on with the EMR (single sign-on). This allowed UAB to disable access to patient data within the care planning system to employees when they left the institution. Second, we added a direct link to the care planning system Web site to the EMR to provide clinicians access to the treatment planning system without the hassle of remembering a Web address or clicking on a separate desktop icon. Third, we built a data connection from the scheduling system to the care planning system so that the name, medical record number, and date of the visit of any patient seen in the clinic would populate into the care planning system. This approach was more efficient and reduced the potential for duplicate patients or errors in transcription. Fourth, a single location within the EMR was needed where all the critical data elements would be documented as data-minable fields for generation of both treatment plans and survivorship care plans. All data connections required testing of the automatic transfer of this information from the EMR to the treatment planning system. Finally, we established the ability to transfer an electronic PDF version of the care plans back into the medical record, as well as to the patient portal. The process of EMR integration required routine meetings with Carevive, UAB’s IT personnel, and clinical staff over the course of 8 months. Although time-consuming and challenging, it provided a unique opportunity for clinicians and IT staff to work together on a common solution. This collaboration ultimately resulted in other improvements to the EMR, such as updates to the staging tab. Conversely, MCI was preparing for a transition to the Cerner EMR and favored an approach of manual entry. This approach allowed for the rapid transition to the implementation phase, resulting in the completion of 1,413 care plans to date, compared with UAB’s 101 care plans. MCI plans to go live with Cerner in late spring and will transition to an interface similar to the one developed at UAB.
Finally, our last lesson learned is to not reinvent the wheel. Although processes and workflows will inevitably differ among institutions, sharing experiences with implementation promotes cross-institutional collaboration and facilitates the development of a learning community. UAB has gained valuable insights about workflow challenges from MCI, and Cerner customers, including MCI, will undoubtedly benefit from UAB’s EMR integration. In addition, adoption of the care planning system includes documentation of common data elements within discrete fields within the care planning system, which will enhance capacity for research across institutions regardless of their EMR.
Although UAB and MCI both report benefits in terms of team building and infrastructure development, we recognize that the literature outlining benefits of treatment plans is limited and primarily involves breast cancer.7,8 Additional evaluation of patient-centered outcomes is needed as the 196 OCM sites develop their strategies to meet the Institute of Medicine treatment care plan recommendations for all cancer types and other practice transformation requirements.