Randall A. Oyer, MD
You would expect patients with suspected lung cancer to be eager to receive care, but that isn’t always the case. MaineGeneral Health, of Augusta, Maine, has had to combat an “I’m going to die from something anyway” attitude that makes patients unlikely to follow up with care recommendations and referrals.
This was one of the problems tackled at MaineGeneral’s Harold Alfond Center for Cancer Care, a development site for a program to improve treatment for Medicaid patients with lung cancer, who are at higher risk of poor outcomes. The Optimal Care Coordination Model (OCCM), sponsored by Bristol-Myers Squibb Foundation and developed by the Association of Community Cancer Centers (ACCC), was established in recognition of the fact that tobacco use is nearly twice as high among Medicaid patients as among the national population—29% of patients covered by Medicaid smoke, and tobacco use is the leading cause of lung cancer.
During the first year of the 3-year project, which concluded in December 2016, studies were made of cancer centers at 5 locations across the United States to identify challenges and success in caring for patients with lung cancer, and these findings were incorporated into planning for the OCCM test model for improved care. Those centers were Florida Hospital Memorial Medical Center; Mary Bird Perkins-Our Lady of the Lake Cancer Center in Baton Rouge, Louisiana; MaineGeneral Health-Harold Alfond Center for Cancer Care; Genesis Cancer Care Center in Zanesville, Ohio; and the Sidney Kimmel Cancer Center-Methodist Hospital at Thomas Jefferson University in Philadelphia. At all sites, program staff, physicians, referring providers, and even lung cancer patients who received Medicaid benefits took part in focus group interviews.
During the second phase of the project, which continues through the end of September 2017, the test version of the OCCM is being drafted. The OCCM builds upon National Cancer Institute Community Cancer Centers Program multidisciplinary care assessment tool and addresses patient access to care, care coordination, treatment team integration, survivorship care, tobacco cessation, physician engagement, and quality measurement and improvement.
For the 1-year final phase, which begins in October 2017, seven ACCC member programs, including 2 cancer centers that participated as development sites, were chosen to test the OCCM by implementing quality improvement projects. “The purpose of the study is to put together coordination programs with more timely access and better outcomes for people who may be underserved by the general medical processes and may have additional medical problems or comorbidities that may require time, attention, and coordination in addition to lung cancer treatment,” said Randall A. Oyer, MD, oncology director of the Ann B. Barshinger Cancer Institute in Lancaster, Pennsylvania. Along with Christopher Lathan, MD, a medical oncologist in the Lowe Center for Thoracic Oncology at the Dana Farber Cancer Institute in Boston, Oyer serves as both the project co-principal investigator and co-chair of the project advisory committee.
Strength of Innovation Defined by Magnitude of Problem
Some intensely challenging problems and innovative solutions were documented as part of the first, investigational phase of the project. At MaineGeneral, the difficulty of getting patients to show up for treatment was compounded by their lack of resources and their tendency to shun treatment. Many suspected cases of lung cancer were picked up only when patients turn up at emergency departments (EDs), which they rely on for primary care. Primary care physicians (PCPs) also tended not to appreciate the value of low-dose computed tomography scans and neglected to have pathology done when sending abnormal images, requiring fresh scans and biopsies at the cancer center.
To combat these problems, MaineGeneral arranged for PCP training both in and out of network to ensure compliance with prescreening protocol and established community-based education sessions to promote the importance of lung cancer screening. Geographic areas with known high tobacco use and high radon exposure were targeted for more focused efforts to identify candidates for screening. The Harold Alfond Center has encountered and solved many other problems related to lung cancer care. Similar barriers to access have been managed successfully at Mary Bird Perkins in Baton Rouge, which made this cancer program worthy of study in developing the OCCM. Patients tended to skip regular checkups and enter the system only after visiting EDs. To make matters worse, Medicaid requires a PCP referral for screening and diagnostic tests. Patients were not getting appropriate referrals through the healthcare system owing to the lack of a clinical pathway for lung cancer.
The solutions enacted at the Louisiana practice included developing a prompt in the electronic medical record so that PCPs would recognize candidates for screening. Further, PCPs were given educational materials on how to talk with patients regarding the risks and benefits of screening. A facility was designated as a “center of excellence” for lung cancer screening, and funds were earmarked to help at-risk populations.
Still, patient tracking issues persisted, Medicaid coverage restrictions posed additional complications, and scheduling and other program access challenges arose from patients’ lack of contact information or transportation.
Mary Bird Perkins standardized care for Medicaid patients; improved coordination of appointments; and encouraged more effective collaboration among surgeons, pulmonologists, and other physicians. Also, patient follow-up improved with the help of “post-op” teams and nurses.
At Florida Hospital Cancer Institute (FHCI) in Volusia County, in the state’s northeast section, one of the challenges was to develop an outreach program that created earlier screening opportunities for patients at high risk of lung cancer. Volusia County has a much higher rate of chronic adult smokers than the rest of Florida: 23% versus 17%. Tremendous delays in care were reported for the Medicaid population, partly because these patients are assigned a lower priority for PCP visits, and low numbers of PCPs and specialists in the area accept Medicaid. PCPs also cap the number of Medicaid patients they see. Most lung cancer patients with Medicaid coverage are stage III to IV by the time they get to the institute, FHCI reported. Owing to contract issues, FHCI had difficulty getting referrals from pulmonologists; instead, patients were sent to academic centers farther away.
The solutions that made FHCI a choice for study in developing the OCCM included closer coordination between PCPs and imaging navigators and radiation oncologists. Other steps forward involved prioritizing thoracic malignancies for surgical care; improving communication between inpatient and outpatient teams; and implementing a lung nodule clinic, as well as a clinical care pathway for lung navigators.
Helping to Overcome the Medicaid Disadvantage
It was clear to the OCCM project contributors that lung cancer is difficult for patients to manage without exceptional support and that Medicaid patients, who have fewer resources, tend to be at a particular disadvantage. “It takes a sophisticated person to be able to navigate the system,” Oyer said. Patients with lung cancer often lack the necessary insurance, education, and financial resources to get by. “Smoking is heavy, and there may be additional health disparities that may affect somebody’s ability to get into the system,” he said. “Sometimes the community hospitals that the patients have access to don’t have well-developed multidisciplinary programs.”
It’s essential to think of these patients as individuals with lung cancer rather than depersonalize them as a population that must be handled en masse, Oyer said. This involves carefully weighing their diverse psychosocial needs, financial needs, and comorbidities, for example. He believes that this evolution in thinking occurred at the development sites that helped sculpt the first outlines of the OCCM.
Improving or starting patient navigator programs has been a foundation of the OCCM, Oyer said. Another cornerstone principle: recognizing the importance of multidisciplinary care team coordination to deliver timely care. “You need to have a diagnostic radiologist, pathologists, medical oncologists, radiation oncologists, and surgeons,” he said.
Oyer stressed the diversity of challenges and resources at each of the development sites and noted that there is no one-size-fits-all approach. Achieving some goals may require more effort and investment for some institutions than for others. “You can’t do the same thing in every program. You have to adapt your methods and organization structure,” he said. “A hospital in New Jersey that has strong financial counselors and social workers can build on them. The hospital may be downtown, and people can get to it easily. On the other hand, in a rural area, people may have to travel a great distance to the hospital, so something you’ll need to coordinate is transportation.”
Having set the criteria for participation and standards for care, the OCCM Advisory Committee will convene in coming months to learn more about the testing sites’ progress with implementing their quality improvement projects. “We’ll ask the hard questions,” Oyer said. “What are the barriers? How did you solve them? How quickly are you getting your patients in, and what support do you need to provide?” Progress with patient and physician engagement also will be reviewed.
No one center is expected to ace every point. In fact, the purpose of the reviews will be to learn from each center’s experiences and share that knowledge with others, Oyer said.
The major questions will revolve around how these cancer centers succeeded in identifying and treating patients with lung cancer who normally skirt the healthcare system or fall through the cracks, Oyer said: “How did you get that patient scheduled for a CT scan, get a lung biopsy done, and get them plugged in to multidisciplinary lung cancer care? How did you turn that person into an engaged patient who had follow-up with your care team? What lessons did you learn that somebody else would have to spend 6 months learning?”
It’s impossible to know many of those answers at the beginning, and it’s only through the experience of one center that others can approach a model like the OCCM and start off on the right foot, without the learning curve, Oyer said. But in a year’s time, newcomers can follow a road map for success based on a lot of accumulated experience—“pretty much smooth sailing in what could have been the wild, wild West,” he said.
The ACCC has long recognized the principle of mass-producing success based on an individual cancer center’s achievement, Oyer said. But equally important is enrolling already successful practice participants in the model, because those are the ones that are likely to break new ground. “The way the ACCC works is, they find people who’ve done some components of what they want to accomplish,” he said. “They find experts and test the findings, and then they come up with something you can do back at home. They’ve done that with molecular testing; they’ve done it for exercise in cancer, for navigation programs, and for lung cancer screening.”