Urgent Symptom Support, Pathways to Reduce ED Use, Care Variation

MikeAt the ACCC Annual Meeting and Cancer Center Business Summit (March 4-6, 2020; Washington, DC), Journal of Clinical Pathways spoke with Mike Koroscik, MHA, MBA, oncology service line executive, Sutter Health (CA), about successful strategies to reduce ED visits and hospitalizations in the community setting as well as embracing clinical pathways to reduce variation in care.

You mentioned in your presentation that Sutter Health is located all across northern California and Hawaii. What are some of the unique challenges that this geographic location offers in terms of patient care?

Mr Koroscik: We treat one of the most diverse populations in America. Our patients come from urban, suburban, and rural areas. Such diversity has a substantial impact on how we deliver oncology care. Sutter as a whole has over 20 locations for oncology care in Northern California. We are affiliated with large medical foundations in California to meet the needs of our patients. One such group—Palo Alto Medical Foundation—provides infusion through their ambulatory services, while hospital‑based infusion is provided at other sites in the Sutter network.

How has Sutter Health embraced clinical pathways to ensure adherence to care and reduce variation across network physicians and locations?

Mr Koroscik: Years ago, we asked ourselves what are the themes and quality measures that we want to target in our oncology service line moving forward? Our number one answer was reducing clinical variance to improve care and outcomes with an additional emphasis on standardizing and coordinating care. We needed to improve outcomes and address cost, as a constant in the health care landscape continues to be lower reimbursement and higher cost. But right at the top of our prioritized list was standardization – not only of how we provide cancer care, but also the therapies we choose to administer. The pharmaceutical component was the very first aspect we targeted in minimizing variation in care.

That being said, there is a balance to be struck between standardizing care and maintaining personalized care for patients. We always want to make sure that the empty chair in the room, so to speak, is the patient. When we rolled out our pathways, we were not driven by cost reduction. The idea or goal was not to cut costs, but rather to improve patient care through better outcomes. Through pathways, we were minimizing off‑label therapy utilization and regimens not considered standard of care.

Believe me, it was not an easy sell among our staff. The medical and radiation oncologists had a lot of questions and reservations. The selling point that we drove home was the pathways were all about improving care first-and-foremost. The aftereffects from there would be better contracting; our drug purchasing would fall in line.

Could you speak further to the strategies you utilized to gain physician buy-in to your pathways?

Mr Koroscik: Change is always a jagged pill in the health care space. We had to sell the pathways to our team, part of which involved proving that pathways were a positive. We learned that it had to be visual in terms of showing clinicians the quality data associated with the roll-out. We had a strong taskforce and advisory group that was committed to transitioning our staff to pathways without threat of discipline.

The software we initially used for our pathways was adding a time constraint to our physician’s already busy workday. Thus, we are in the process of creating new metrics and shared pathways around pathway utilization and adherence.

Has Sutter Health begun adopting telehealth practices or other innovative technological approaches to lower ED utilization or improve symptom management?

Mr Koroscik: Telehealth is definitely in our plans. We have rural hospital sites that provide infusion onsite, so these locations are primed for a telehealth system that can provide infusion after the first consult. Sutter has an innovation department that is heavily focused on telehealth. We are preparing to utilize telehealth to address symptom management across the entire network. We are fixated on improving survivorship and bringing comprehensive care to our rural markets in order to minimize patient travel.

In fact, we have begun offering telehealth services in other specialties, including cardiology through the utilization of an electronic stethoscope. Sharing the technology and resources with other specialties provides the needed economy of scale. 

As Sutter Health continues the shift towards value‑based care, what areas other than ED visits are you planning to target to lower health resource utilization and costs?

Mr Koroscik: Our hope is that pathways will reduce variation, decrease costs, and improve outcomes. We are embracing technology to achieve a lot of our efficiencies and obtain robust data to be able to survive, and thrive, under value-based and population health initiatives. 

Now is the time to data-mine and create an oncology dashboard that reflects value‑based or population‑based metrics. We have initiated clinical risk-stratification programs, first of which is in cardio-oncology. We also know from our database that there are substantial cardiovascular comorbidity issues.

We want our pathways to embrace overall population health outcomes as we transition to bundled payments. We will continue to look at the other high-frequency comorbidities in our population, but for the time-being, cardio‑oncology risk-stratification is at the top of our priority list.

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