Care Coordination for the Oncology Survivorship Patient: A New Focus

Posted by Cam McClellan Teems

October 21, 2019 at 4:28 PM

The Commission on Cancer's DRAFT Revised Standards (May 16, 2019) and its new Standard 4.8, include a clear impact on the previous Standard 3.3  It appears the the CoC is shifting the main emphasis from the actual provision of the Survivorship Plan document to a broader provision of coordination and care for those events/items in the Plan.  After all, what benefit is a document telling a patient about recommended screening-for-recurrence events or possible late effects - if the patient is ultimately left to their own devices in order to maintain a surveillance schedule and manage their anxiety of recurrence. A Plan and help with that Plan's contents is the proverbial brass ring here.

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Topics: survivorship, care coordination

Care Coordination is NOT a Synonym for Discharge Planning

Posted by Stefani Daniels, MSNA, RN, ACM, CMAC Founder and Managing Partner Phoenix Medical Management, Inc.

September 25, 2019 at 3:31 PM

Review the literature and you'll find over 40 definitions of care coordination. In 2007, the AHRQ in its landmark paper Closing the Quality Gap, described it as a "deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services." Subsequent publications have been pretty consistent in noting that care coordination activities should be reserved for targeted populations of high risk or pre-high risk patients in the community and in the hospital.

However, when you dig into articles written by and about hospital case management, you will find that many authors seem focused on using 'care coordination' as a metaphor for coordinating the discharge plan from the hospital to the community and how a well coordinated discharge plan can reduce emergency department visits and readmissions. But if you refer to definitions and descriptions of care coordination published by the AHRQ, the Institute of Medicine, the National Health Policy Forum, the US Department of Veteran Affairs and dozens more, the intent of care coordination is the facilitation of the most appropriate care, in the right order, at the right time, and in the right setting. In my mind, that conjures up a lot more than coordinating a discharge plan.

The targeted populations mentioned in the majority of research articles are those with complex medical needs and related underlying factors that impact their health - social, environmental, financial and cultural. These vulnerable patients would undoubtedly benefit from targeted care coordination beginning at the time of hospital admission and extending through community-based transitional care. Many of the more recent studies demonstrate the success of care coordination models that span the continuum such as The Johns Hopkins Community Health Partnership (J-CHiP) initiative. Their model starts with hospital case managers in two of their East Baltimore hospitals and extends into the community for those patients discharged to local skilled nursing facilities as well as several ambulatory primary care sites.

Nationally, hospital execs and their ACO and care coordination colleagues are working behind the scenes to identify community partners and stakeholders that can assist in improving care coordination across the continuum. Then, using claims data, clinical data elements from the EHRs, utilization data, and/or reports from payers, they risk-stratify entire populations to identify problems, implement evidence based interventions and address the gaps in care that result in readmissions and avoidable visits to the ED.

While managing the safe transition from one level of acute care to another and from acute care to the community is a 'given' for most hospital case managers, care coordination is the idea that all the hospitalists, consulting specialists, nurses and care team members are communicating and sharing information to ensure that everyone is acting as a team to meet the patient's needs. It's about working together rather than working as separate entities. Unfortunately, this is far from what most patients experience. Breakdowns are everywhere and they are not exclusive to patients with complex health needs....they happen to all of us.

So, it isn’t surprising that when The Commonwealth Fund ranked the healthcare systems of 11 industrialized countries, the U.S. was not ranked highly for its ability to provide coordinated care. In fact, in comparison to the other countries studied, the U.S. placed last in efficiency—largely due to lack of communication among healthcare providers.

At its core, care coordination is just what the name implies: A mechanism through which teams of health care professionals work together to ensure that their patients’ health needs are being met and that the case manager is pro-actively advocating for the right care and at the right time. Care coordination activities are numerous and varies from organization to organization. But at its heart it means having a single consistent resource to mobilize multiple participants who individually provide specialized knowledge, skills, and services, and who together potentially provide a comprehensive, coherent, and continuous response to a patient's unique care needs.

In my view, a robust care coordination program targeted on the most needy inpatient population pays off financially and in terms of customer satisfaction. But it requires the persistent support and encouragement of the executive team and medical leadership to re-engineer the culture and successfully overcome the tensions and paradoxes of new expectations.

Is it worth it? Of course it is. Coordination is necessary when participants are dependent upon each other to carry out disparate activities in a patient's care. Nevertheless, patients with serious illnesses or chronic conditions, who account for a disproportionate share of hospital costs, tell stories about the gaps that often occur in communication between patients and care team members, as well as between specialists. These communication gaps can hinder the multidisciplinary group from working toward common patient-centered goals in a coordinated “interdisciplinary” manner.

Over the years, I've told client hospitals that care coordination is too expensive to provide to all inpatients and isn't needed by most. I stand by that advice knowing that according to MedPac around .3 to 25% of inpatients are outliers - those patients whose costs or days in the hospital exceed the expectations due to the complexity of their medical conditions or their challenging post acute needs. Those are the hospital's most vulnerable patients and in a marketplace punctuated by value based payment systems, they are the ones who warrant oversight by the hospital case manager to help them and their families through the journey to recovery. As Chen wrote back in 2000, “Case management implicitly enhances care coordination through the designation of a case manager whose specific responsibility is to oversee and coordinate care delivery [targeted to] high-risk patients [with] diverse combinations of health, functional, and social problems.” The same holds true for 2019.

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Topics: care coordination, discharge planning

Better Care Coordination is a National Priority

Posted by Excerpt from Outside Publication

June 26, 2019 at 4:01 PM

See OncologyLive > Vol. 20/No. 12  for full article, Clinics Strive to Improve Revenue and Patient Care Amid a Growing "Cost Consciousness".

"Better care coordination has been identified by the Institute of Medicine (IOM) as one of multiple national priorities for action to improve the quality of healthcare.2 Care coordination can take many forms—follow-up on medication adherence, appointment monitoring, hiring of clinical coordinators, establishing after-hours portals, holding care team consultations—and oncologists have been working harder on these points, spurred in part by the OCM and CMS’ growing, incentive-based emphasis on value-based care. Many factors impair coordination and contribute to poor outcomes. These range from poor follow-up on testing to electronic health records that don’t synchronize with other digital platforms.3

Privately developed models of care that emphasize better coordination have also emerged. The oncology patient–centered medical home has been touted as being able to save million per physician per year. It can align systems and resources and thus reduce fragmentation, support shared decision making, and better control costs, according to chief architect John D. Sprandio, MD, chief of medical oncology and hematology at Consultants in Medical Oncology and Hematology and director of the cancer program at Delaware County Memorial Hospital, in Upper Darby, Pennsylvania.4

However, as with any transformative internal revamp, the model requires “nothing short of a substantial, disruptive, and coordinated response by the practice to reengineer the delivery of care,” as well as the creation of a sustainable business model that can be achieved only by actively engaging with payers in the development of new payment methodologies, according to Sprandio. Lighter measures are also available to achieve coordinated care.

One way is to hire nurse navigators, according to Mark Krasna, MD, who spoke on the subject at the ACCC’s 2018 annual meeting. Nurse navigators work with staffers and doctors at all levels in oncology practice and can help achieve consensus on an individual patient’s care, Krasna stated at the event. He added that care coordination reduces unnecessary x-rays and magnetic resonance imaging, among other tests, and puts practices in good stead with payers. He also noted that patient satisfaction is higher at facilities that work hard on aspects of care coordination. From a business perspective, these satisfied patients may help boost referrals by telling friends and family about their experience with the practice, Krasna noted.5

Care coordination cannot help but be beneficial for patients, Oyer added. A well-oiled system for patient referrals can add to the business benefits of coordination, which is helped along if oncologists pull out all the stops. “When you have a streamlined referral process, that is attractive to patients, and they are more likely to choose you to provide their care,” he said.

In a sense, care coordination is also workforce optimization, and that is good for running a business, Oyer said."

1Association of Community Cancer Centers 2018 survey finds multiple barriers to cancer program growth [news release]. Rockville, MD: Association of Community Cancer Centers; January 16, 2019. Accessed May 22, 2019.
2Initial national priorities for comparative effectiveness research. National Academies website. Published June 2009. Accessed May 22, 2019.
3Weaver SJ, Jacobsen PB. Cancer care coordination: opportunities for healthcare delivery research. Trans Behav Med. 2018;8(3):503-508. doi 10.1093/tbm/ibx079.
4Sprandio JD. Oncology patient-centered medical home. J Clin Oncol. 2012;8(35):47s-49s. doi: 10.1200/JOP.2012.000590.
5Cryts A. Improve care coordination in cancer care: 2 key focus areas. Managed Healthcare Executive. March 16, 2018. Accessed May 22, 2019.

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Costs of Readmissions are Up:  Have You Done Your Service Line Math?

Posted by Cam McClellan Teems

June 24, 2019 at 6:13 PM

The Centers for Medicare & Medicaid Services penalized half of U.S. hospitals for their readmission rates in 2016. The penalties are controversial, and major professional organizations such as the American Hospital Association, have questioned the methods used to assess the data.  Recently, the AHRQ examined readmission trends and costs using the 2010-16 Nationwide Readmissions Database.

Here is a small sample of a recent list that was published by AHRQ with average readmission costs and readmission rates for the top 2.  This includes patients 1 year and older, readmitted for any cause within 30 days of first admission:.

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Guest Blog: Still Using Fax Machines And Sitting On Hold When Scheduling Outbound Referrals For Patients? It Can Be A Nightmare - But It Does Not Have To Be

Posted by Guest Blogger

April 1, 2019 at 10:07 AM

Here is the situation.  Scheduling for patients with outside providers is often the hardest part of a navigator or care coordinators role. It is almost never immediate, takes multiple phone calls and compliance rates with the planned appointment is far from a given.  In fact, studies show that >40% of patients do not follow up with the referral appointments their doctor recommends. Why is that?

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SDoH Can Derail Your Carefully Constructed Care Plans

Posted by Cam McClellan Teems

January 10, 2019 at 9:52 AM

Consider, for a moment, some statistics[3]:

  • 28% of US adults report that they have at least two chronic conditions
  • 26% of US adults say that they had experienced emotional distress in the past year that was difficult to cope with alone.
  • US adults were more likely than adults in all other countries to report that they were “always” or “usually” worrying about having enough money to buy nutritious meals and to pay their rent or mortgage.

It is not just the complex disease profile and treatment plan. In fact, those well-crafted plans can be easily derailed if the conditions in the places where people live, learn, work, and play are contributing to stress and lack of an ability to heal.

Patient conditions are not only clinical. They might be a cancer patient living in a shelter and facing daily transportation issues to get to chemotherapy...or a recent overdose or behavioral health illness patient who needs hand-holding to elect treatment...or a low-income diabetes patient with unstable access to nutritious food. The list goes on doesn't it? The role of the Care Team is rooted in the disease. However, the disease requires a full understanding of the patient's personal situation & environment in order to truly care for them and talk to them in an impactful way. It is the only way to really help them, reduce costs, and improve the system.

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The 71%: Is Your Cardiovascular Continuum Flatlining?

Posted by Cam McClellan Teems

September 12, 2018 at 2:18 PM


Cardiovascular disease is the leading cause of hospitalization and mortality [1]. Every 40 seconds, one American will suffer a heart attack, which is among the top ten most expensive hospital principal discharge diagnoses.[2] And to add insult to injury, the The National Health and Nutrition Examination Survey (NHANES) showed that cardiovascular expenses have one of the largest portions of current spending—an amount estimated to triple over the next 20 years.  This means that the cardiovascular care continuum is an imperative for most providers, hospitals and health systems. 


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Topics: care coordination, cardiovascular continuum

Sorry….Wrong Number!

Posted by Gary Winzenread

July 26, 2018 at 9:34 AM

What can we learn from the Caresync story?

As an entrepreneur trying to innovate in the healthcare market, I have a soft spot in my heart for others taking on the challenges of changing what may be the most regulated, conservative, bureaucratic and risk averse market in the American economy. The point of this article is not to take any pleasure in the failure of another’s attempt at innovation in this tough space. In fact, I deeply respect the effort Caresync, and many others that met the same fate in this industry, have made to improve our health system by lowering costs. But the silver lining of any failure is the learning that it grants us, which has made me ask the question, What can we learn from the Caresync story?

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Topics: Financial Incentives, care coordination

The 71%: Gaining control of the care for your most expensive cancer patients

Posted by Cam McClellan Teems

June 25, 2018 at 4:05 PM


The Chronic Care Model (CCM) that emerged in the 1990s - was a model designed to retool primary care and implement critical components to proactively manage patients with chronic conditions[1]. However, the model could not keep pace with the sickening of our population (e.g cancer, heart disease, diabetes, addiction, etc). Today, most sick patients present with multiple chronic conditions (now called "multi-morbid") and increasing psychosocial complexity. Most alarming is that these patients face growing and overwhelming risk resulting from the sum of uncoordinated responses to each of their diseases.

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Topics: care coordination

Care Coordination Roundtable Recap

Posted by Cordata Health

April 6, 2018 at 8:41 AM

Cordata recently held the first in a series of webinars bringing together leading voices in care coordination to discuss its application across the healthcare landscape. The discussion featured Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, along with Ellis “Mac” Knight, MD, MBA, senior vice president and chief medical officer of Coker Group and Kimberly Zukowski, LMSW, CCM, Director of Care Coordination at WellStar Health System.

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Topics: CoC, case management, care coordination, patient advocacy

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