December 2013 Edition Vol.11, Issue 12

Innovative Cancer Care and the Initiation of the COME HOME Medical Home Program

Innovative Cancer Care and the Initiation of the COME HOME Medical Home Program (cont.)

In phase 1 of the COME HOME model, patient services include:

  • Patient education and medication management
  • 24/7 practice access
  • Telephone triage
  • Triage pathways
  • Night and weekend clinic hours
  • On-call physicians
  • On-site or near-site imaging and laboratory testing
  • Admitting physicians who shepherd patients through inpatient encounters, avoiding handoffs and readmissions, and ensuring seamless care

Software programs will allow monitoring of how well physicians in each practice are managing patients. Compliance rates with pathways will be measured as will expenses of the care.  The software will allow the lead physician at each practice to review and discuss with colleagues how they are doing and where improvement needs to be implemented. Physicians will be paid a set amount instead of fee for service.

The projected savings to CMS are shown in the table.

Case Study: The Maine Center for Cancer Medicine

The Maine Center for Cancer Medicine (MCCM), a private physician-owned practice for over 30 years, with operations in four sites, is one of the 7 practices included in the COME HOME medical home program. Addressing the audience at the CCBS, Tracey Weisberg, MD, President, discussed the difficulties of transitioning from a primary nurse model to a medical home model.

“Our vision has always been to provide the highest quality, cost effective cancer care in the region,” she said. One of the tools that helped MCCM achieve this goal was the implementation of an EMR system. MCCM is on their third system and “each one has helped us shore up our practices and improve care,” she said.

When MCCM was approached by Barbara McAneny as a potential COME HOME medical home site, Weisberg asserts that McAneny saw the building blocks at MCCM that could potentially help her deliver on her overall goal of saving money while improving care.

The basic tenet of the COME HOME program is to be present for the patient at the time of his/her greatest need. In order to do this, Weisberg said, “We needed to look at our staffing and see that everyone was doing their job at the top of their licensure.” One of the greatest challenges Weisberg said she faced was how to get her staff on board and make the transitions necessary to not only execute the tenets of the COME HOME program, but that would also take her organization into the reality of the patient-centered medical home mindset.

“We had an economically inefficient model of primary nursing for over 30 years,” Weisberg said, and that included a 9 to 5 working shift mentality. Transitioning from that model was difficult and was met with much resistance. The physicians at MCCM were enthusiastic, Weisberg said, but the nursing staff was skeptical about having to work extended hours and on weekends.

“We had a much-loved lead nurse who could not envision any kind of change, not in hours, and not in a phone system revision, and it eventually cost her, her job.” This put an added level of disruption to the transition that MCCM is still feeling the effects. Many of the nurses had a perception that “there was a perceived rigidity of following an urgent care pathway” which they said they were already following, but Weisberg disagreed.

The frustration Weisberg met, ultimately led to a breakthrough and the urgent care hours were eventually implemented. With the new phone system in place, every phone call is now documented and “we are able to gather data about what happens on that call and the outcomes” associated with that call.

In the absence of a lead nurse, the remaining nurses got together and created a new nursing council that reviews all of the protocols needed for the successful functioning of a medical home. Reaction to the new program has been enthusiastic.

“Once we implemented our extended hours, the patients have been deliriously happy. Especially for the weekend hours,” Weisberg said.

The model set in place by COME HOME has prevented many patients with cancer from going into the ER, Weisberg said. In fact, their hospital association that wants to use MCCM’s data to reduce their own ER admissions, and private payers have also expressed interest in their new model. “It’s been a huge win for everyone,” she said.

Summary of Key Points to the COME HOME Program

The BEST practices tools of the COME HOME program include:

  • Use of Electronic Health Records to share/track real-time patient data and to monitor quality of care.
  • Creation of triage, diagnostic, and therapeutic pathways.
  • Team-based care that includes all of the members of a multidisciplinary care-team that is dedicated to practicing at the top of their license in order to keep patients out of the ED and unnecessarily hospitalized, through active disease management, patient education, and on- or near-site laboratory, imaging, and pharmacy accommodations.
  • Enhanced access to the medical team with an open 24/7 triage line, extended weekday and weekend hours, same day appointment availability, and automated pathway follow-up reminders for triage nurses.
  • Financial support for medical home services.


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