Chronic care management: An opportunity to drive quality outcomes in oncology care.

Abstract

444 Background: CMS approved Chronic (CCM) and Principal Care Management (PCM) to improve patient care. These services are typically non-face-to-face; providers can bill ≥ twenty minutes /month. In oncology, this may help with comorbidity and symptom management to reduce the risk and expense of avoidable hospitalizations and ER visits and pay providers for time spent. In 2021, a system of community cancer centers initiated a program with a partner to manage chronic conditions more effectively at home. Approximately three hundred people were enrolled. A review of the data found that patients did not meet the medical criteria for the program, and care was not billable. An internal program was created to improve the enrollment process and financial sustainability. A clinical needs assessment was completed with our oncologists, outlining revised criteria for patient enrollment. Qualified patients were enrolled by their attending oncologist during the initial face-to-face visit and assigned a dedicated RN. Methods: Three hundred unenrolled, actively treating patients were randomly selected from January 2023 to May 2023 by a group of data analysts not associated with the program to be compared to enrolled patients who have been enrolled on average six months. Patients were compared by age, gender, cancer type, and race. The LACE Index for Readmission, a validated tool using the length of stay, acuity of admission, comorbidities, and ER visits to predict the risk of readmission, was done retrospectively by RNs for all patients. Enrolled patients received a comprehensive clinical needs assessment by RNs, and a provider-approved care plan was created. RNs provided patients with education on lifestyle modification and assisted in setting achievable goals. The care plan was monitored with weekly calls, providing the opportunity to respond to patients’ needs proactively. Symptom and medication management were provided, and psychological and nutritional needs were addressed. This coordination of services was documented in the electronic health record, and superbills were created and sent to billing and coding monthly. Results: See table. Conclusions: The purpose of this study was to compare hospital admissions between the groups. Our findings suggest that CCM and PCM may reduce unplanned admissions, with physician engagement pivotal in driving appropriate enrollment. The current program is labor-intensive and further investigation is required to determine the most cost-effective way of scaling the program with the possible use of artificial intelligence, RPM, or other technology.[Table: see text]