The Seven Domains of the OMH Standards

An Oncology Medical Home should actively engage with patients to collect feedback and improve treatment. These goals may be accomplished by the oncology practice staff providing education to empower the patient with knowledge about their disease so that expectations are realistic and shared by the team throughout the treatment plan. Understanding the side effects patients may encounter and knowing who and when to call a health care professional have been found to significantly reduce costs of care by keeping patients out of the emergency department (ED) and the hospital as much as possible.[1] An Oncology Medical Home should also have staff to provide financial counseling and access to financial assistance programs. Lastly, patients should have real-time access to their personal medical record, plan for treatment, and educational materials.

Data suggests that lack of access to a patient’s oncology practice when the patient has symptoms during the day, in the early evening, and on weekends leads to more ED visits and unplanned hospitalizations. An Oncology Medical Home practice is required to develop the capability to provide expanded access and an evidence-based symptom triage system to ensure that patients can easily access the practice and their providers. There is urgent care through same day appointments, with 24 hours per day/7 days per week access to a clinician who has real-time access to patients’ medical records. Multiple studies have shown the potential for Oncology Medical Home care management strategies to reduce hospital admissions and emergency room visits.[2] [3] [4] In one such study, hospital admissions per chemotherapy patient, per year started at a rate of 1.08. By the end of the study, the rate of hospital admissions had decreased 51%.[5]

This capability is more than simply having a physician on call. Ideally labs, imaging, hydration, antibiotics, and other symptom management medications are available on-site or at least in a coordinated, expedited manner. This may be in the form of remote access, including telephone access and arrangements with urgent care facilities.

Studies have shown that the application of value-based clinical pathways – clinical pathway built by selecting the most appropriate option based on efficacy, potential for side effects, patient preferences, and cost – result in lower anti-cancer and supportive drug costs. Drug costs associated with use of off-pathway anti-cancer regimens can be upwards of 2.7 times that of on-pathway regimens.[6] [7] Use of on-pathway regimens also results in lower supportive care drug, diagnostic, and hospitalization costs.[8] [9] Initiatives involving implementation of clinical treatment pathways have resulted in increased compliance with on-pathway selection and drug savings from 5-37%.[10] [11] [12]

Oncology Medical Home practices either use practice-developed pathways for their common cancers or implement a commercially available oncology clinical pathways program such as New Century Health, Elsevier’s ClinicalPath, Value Pathways powered by NCCN, or Philips IntelliSpace Precision Medicine Oncology Pathways powered by Dana-Farber. Alternatively, practices may implement NCCN Categories of Preference as integrated into their EHR or decision support tool. Practices implementing Categories of Preference must track and report adherence according to the standard. Practices may use a single-institution oncology clinical pathways program that has been assessed against ASCO’s Criteria for High-Quality Clinical Pathways.[13]

Health equity is a priority for the practice throughout the continuum of cancer care. The practice should address health equity guided by the ASCO policy statement on cancer care disparities which endeavor to: (1) ensure equitable access to high-quality care, (2) ensure equitable research, (3) address structural barriers, and (4) increase awareness and action. Practice policies will address developing awareness of conscious and unconscious biases of all practice team members and should be a focus of the practice. Resources should be made available to assess & drive change where appropriate.

Within an Oncology Medical Home practice, the care team is created by determining the medical, psychosocial, economic, and support needs of the patient, determining how the practice can meet those needs and assigning the team member with the appropriate level of education and training to perform each service. Members of the team must be able to discern from the electronic medical record that the patient’s needs are met. In addition, data to evaluate the outcomes of all facets of treatment must be available in real time to allow the practice to improve on the services given. Within the Oncology Medical Home practice itself, a team is led by a physician and comprised of nurses, pharmacists, medical technicians, care coordinators, first responders (telephone operators), and other appropriate team members. Disease management, patient education, and on/near site laboratory, imaging and pharmacy services are all delivered in a caring environment that enhances patient satisfaction.

Not all the care needed can be delivered within the walls of the practice, so an Oncology Medical Home practice must have established relationships with outside physicians when needed for the management of non-cancer symptoms. Oncology Medical Home practices have established communication processes in place to keep other physicians informed of the patient’s treatment plan and current health care status. Patient navigation and care coordination includes support services and community resources specific to the patient’s needs, such as translation, transportation, nutrition, rehabilitation, and social services. Health equity is a priority for the practice throughout the cancer care continuum of medically underserved populations, including the identification and mitigation of disparities among racial and ethnic minorities, sexual and gender minorities, older adults, rural populations, poverty, socioeconomic, low literacy, inadequate health insurance, and cultural differences.

If a patient requires hospitalization, the care team focuses on an established inpatient care plan where the oncologist either manages the patient or co-manages the patient with hospitalists and the patient’s primary care physician. When implementation of an end-of-life care plan is needed, this team collaborates with palliative care and hospice to facilitate the transition of patients off of active treatment.

Cancer care that is continuously improved by measuring and benchmarking results against physicians within the same practice (peer review), as well as against other oncology groups, helps to ensure continuous improvement and adoption of best practices. As quality goals are achieved or as standards of care evolve, those measures should be retired and replaced with new measures. Doing so continues to “raise the bar” in care delivery. In order to capture and exchange information for practices to continually monitor, report and improve processes and outcomes, a practice must have a fully implemented certified electronic health records system.

Oncology practices that wish to achieve Certification will be required to submit data to be used to monitor compliance with mandatory quality measures. Administration and monitoring of an oncology-specific patient satisfaction survey with evaluation of benchmarking is a critical tool for implementing quality improvement. Patient satisfaction surveys are to be continuously reviewed and results acted upon if changes are warranted. The goals of the surveys are to educate and inform the practice of any patient concerns and to focus and facilitate quality improvement efforts.

In 2010, Medicare costs for cancer care in the last year of life totaled $37 million, mainly due to undesired hospitalizations, ED visits, and intensive care unit stays. High utilization of cancer treatment at the end of life poses a burden to the health care system and may represent poor outcomes from the perspective of patients. Studies suggest that patients with advanced cancer prefer to have less aggressive life-prolonging treatment and more comfort-focused care including support for existential and physical suffering, and to avoid intensive inpatient settings at the end of life.[14] [15] The National Quality Forum endorsed the use of several measures as indicators of poor quality of care at the end of life such as the use of chemotherapy in the last 14 days of life, stays in the intensive care unit in the last 30 days of life, and enrollment in hospice for fewer than three days.[16]

Oncology Medical Home practices will offer an advance care planning discussion and complete a goals of care discussion with all patients that recognizes the individual patient’s needs and preferences. Palliative care will be introduced early in the patient care process for all patients with cancer; for patients with advanced cancer and/or metastatic cancer or patients with limiting co-morbid conditions, the practice performs an advance care planning discussion including review of advance directives, agent for medical decision making, goals of care, and symptom management; and provide patient-centered access to care for patients at the end of life to avoid unnecessary and unwanted ED visits and potential hospitalizations.

Chemotherapy Safety Standards serve as a framework for practices to be recognized for exemplary commitment to quality and safety in oncology patient care. Practices desiring to achieve Certification must meet Chemotherapy Safety Standards – Oncology Medical Home Chemotherapy Safety Standards are identical to the QOPI® Certification Program (QCP) standards for chemotherapy administration safety – through one of the following options:

1. Current QOPI Certification status within the last 24 months of the 36-month re-certification cycle. QCP Certification status must be maintained to maintain Certification status; OR
2. Demonstration of compliance through Pilot site survey.[17]

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