Abstract
44 Background: Comprehensive oncology care management is commonly built on expert clinical support and coordinated services, but lacks a community focus during critical phases of the cancer journey. However, a community-embedded approach extends past practice walls by incorporating local resources and identifying barriers to care in-between office visits. The cycle of care management adheres to the following objectives: Improve health outcomes; Engage the patient, their family and healthcare team; Advance payor efficiency and cost savings; Support the treatment plan in the community. Methods: Stratification Technology Platform & Levels of Care: A risk-based process is implemented through proprietary stratification software, which combines all data points of the healthcare system. A three-step risk acuity score is calculated for each patient based on claims data, diagnoses and disabilities to assure care is tailored to meet individual needs. Patients are then designated to care programs in accordance to their various risk levels. This allows for personalized care plans and staff workflows. Care Teams: Teams of a care coordinator, registered nurse and social worker provide consistent healthcare navigation, monitor patients’ treatment adherence and improve health outcomes. They act as a safety net for patients and their families at all times. Results: 31% decrease in ER visits; 51% decrease in hospital admissions; Hospice conversion at 8x national average; Improved side effects management; ROI of 3:1. Conclusions: Through community-embedded oncology care management, patients not only receive the proper level of care, but also show various improved health outcomes. Providers and patients see decreased emergency room visits, shorter hospital stays and improved quality of life, while payers experience tremendous cost savings due to smarter spending and utilization management. Practices continue to recognize community-embedded care management as a transformative standard of treatment that is central to positive health outcomes. However, there is always more to learn and improve upon, so constant evaluations of quality metrics are essential to provide the very best to patients, providors and payers.
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