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.