CARRIE TOMPKINS STRICKER, PHD, RN CHIEF CLINICAL OFFICER & CO-FOUNDER
CAREVIVE SYSTEMS, INC.
LEVERAGING TECHNOLOGY AND PATIENT ENGAGEMENT TO OPTIMIZE VALUE-BASED CANCER CARE:
THE CAREVIVE EXPERIENCE
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OBJECTIVES
▸ Provide a overview of value-based care delivery and reimbursement models in oncology
▸ Discuss the role of technology and patient engagement in achieving value-based cancer care
▸ Overview the development, implementation, and evaluation of Carevive products in the real world
▸ Including evolution over time in response to market drivers
▸ Share lessons learned from bridging the academia-industry interface
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BACKGROUND 1. U.S. healthcare system is regularly criticized as being inefficient, inaccessible and
way too costly
2. As a result, the healthcare system is undergoing a transformation from traditional “volume-based” to the notion of “value-based” care
3. Cancer care, with high variability in terms of both outcomes and cost, is of particular interest as a candidate for transformation
4. This transformation is being catalyzed in large part by the Affordable Care Act (“ACA”) and it’s various alternative payment model (APM) initiatives
5. CMMI’s new Oncology Care Model (OCM) is one such APM initiative designed to financially incentivize oncology providers to engage in the transformation [innovation.cms.gov/initiatives/oncology-care]
6. REFORM IS HERE TO STAY. Cost of healthcare is unsustainable. 17.5% of GDP in 2015 and climbing. Medicare to be insolvent by 2020. Regardless of new Administration, Congress has weighed in: volume ! value (MACRA)
3 Courtesy of Ron Barkley, MS, JD - [email protected]
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WHY DOES HEALTH CARE DELIVERY AND REIMBURSEMENT NEED TO CHANGE?
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THE EVOLUTION OF CANCER CARE REIMBURSEMENT The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed in 2016, effectively repealing the sustainable growth rate (SGR) and introducing comprehensive changes in how Medicare pays physicians for services.
As the policies passed in MACRA, new Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs) will profoundly impact reimbursement and care delivery for oncology practices throughout the United States.
The first CMS-sponsored Alternative Payment Model, the Oncology Care Model (OCM), was announced in April 2016
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CHRONOLOGY OF ONCOLOGY ALTERNATIVE PAYMENT
2009 Drug Pathways Compliance
Payor waives pre-auth, pays > for generics if
drug pathways compliance. CareFirst
BC , Highmark BC, Michigan BC
2009-201
2
United H/C Episodes Model
Replaces % drug mark-up with pre-set drug margin payment. Findings published 2014: drug costs not reduced, but overall “spend” down by 11% annual
2010 Oncology Medical Home (OMH)
John Sprandio, MD, Drexel Hill, PA. Applies to NCQA for PCMH certification and originates the OPCMH model
2010 -
2012
US Oncology - Innovent Model
Aetna + Texas Oncology. Pro-active
care management reduces ER and
inpatient costs. 12% annual by year 2
2011 Priority Health OMH
Priority Health Plan and Michigan oncologists.
$550 per patient reduction in ER and
hospitalization costs May 2012
Oncology ACO
Baptist Health + Advanced Med
Specialties + Florida Blue. Add Hospital to
OMH = Onc ACO. Shared savings
May 2014
Anthem Cancer Care Quality
$350 per treatment patient per month for
pathway compliance + care coordination
7
Chronology)of)Oncology)Alternative)Payment
2009 Drug)Pathways)Compliance))
Payor)waives)pre=auth,)pays)>)for)generics)if)drug)pathways)compliance.))CareFirst)BC),)Highmark)BC,)Michigan)BC)
2009=2012 United)H/CEpisodes)Model)))
Replaces)%)drug)mark=up)with)pre=set)drug)margin)payment.)Findings)published)2014:)drug)costs)not)reduced,)but)overall)“spend”)down)by)11%)annual)
2010 Oncology)Medical)Home))(OMH)
John Sprandio,)MD,)Drexel)Hill,)PA.)Applies)to)NCQA)for)PCMH)certification)and)originates)the)OPCMH)model))
2010)= 2012 US)Oncology =Innovent Model)
Aetna +)Texas)Oncology.)Pro=active)care)management))reduces)ER)and)inpatient)costs.)12%)annual)by)year)2)
2011 Priority)Health)OMH
Priority Health)Plan)and)Michigan)oncologists.)$550)per)patient)reduction)in)ER)and)hospitalization)costs))
May)2012 Oncology)ACO Baptist Health)+)Advanced)Med)Specialties)+)Florida)Blue.)Add)Hospital)to)OMH)=)Onc ACO.)Shared)savings)
May)2014) Anthem)Cancer)Care)Quality
$350)per)treatment)patient)per)month)for)pathway)compliance))+)care)coordination))
4
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CHRONOLOGY OF ONCOLOGY ALTERNATIVE PAYMENT
Aug 201
4
OCM Design Paper
OCM Model to improve quality, reduce costs for
Medicare FFS beneficiaries
undergoing chemo Oct 2014
Aetna Oncology Medical Home Program
Care coordination activities. Enhanced
generic drug payment + shared
savings
Oct 2014
Horizon BC NJ Episodes of Care
Horizon BC – RCCA retrospective
bundled pricing for breast cancer
treatment Dec 2014
MD Anderson – UHC
Bundled pricing: head & neck cancers. All care for one year.
May add lung, prostate
Apr 2015
Medicare Access & CHIP Reauthorization Act
Congress weighs in: MACRA repeals SGR. Mandates merit-based pay (MIPS) or advanced APMs. OCM 2-sided risk qualifies as an APM
July 2015
Comprehensive Care for Joint Replacement (CJR)
MANDATORY hip & knee bundled pricing in 75 markets – mandatory as harbinger of future?
July 2016
OCM Launch Date
195 OCM Participants
scrambling. $160 PBPM for 6-mo
Episode + performance-based
pay (PBP)
8
Chronology)of)Oncology)Alternative)Payment
Aug)2014 OCM)Design)Paper OCM)Model)to)improve)quality,)reduce)costs)for)
Medicare)FFS)beneficiaries)undergoing)chemo)
Oct)2014) Aetna)Oncology Medical)
Home)Program)
Care)coordination)activities.)Enhanced generic)
drug)payment)+)shared)savings)
Oct)2014 Horizon)BC)NJ)Episodes)of)
Care)
Horizon)BC)– RCCA)retrospective bundled pricing)
for)breast)cancer)treatment)
Dec 2014 MD)Anderson)– UHC Bundled)pricing: head)&)neck)cancers.)All care)for)
one)year.)May)add)lung,)prostate
Apr 2015 Medicare)Access)&)CHIP)
Reauthorization)Act
Congress)weighs)in:)MACRA)repeals)SGR.)
Mandates)meritVbased)pay)(MIPS))or)advanced)
APMs.)OCM)2Vsided)risk)qualifies)as)an)APM
July)2015 Comprehensive)Care)for)
Joint)Replacement)(CJR))
MANDATORY)hip)&)knee)bundled)pricing)in)75)
markets)– mandatory)as)harbinger)of)future?)
July 2016 OCM)Launch)Date)))) 195)OCM)Participants)scrambling.)$160)PBPM)for)
6Vmo)Episode)+ performanceVbased pay)(PBP)))
5
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Shared Savings
1 - sided risk
FAMILY TREE OF ONCOLOGY ALTERNATIVE PAYMENT
Pay for
Enhanced
Services
Pay for
Pathways
Compliance
©CCBD Group. 2016
Volume-Based
Fee-for-Service
Shared Savings
2 - sided risk
Bundled Price
Episode of Care
Oncology
Medical Home*
Bundled Price
Specific Treatment
?
*OMH Key Features: pathways compliance; pro-active care management; end-of-life planning (NCQA ‘10; Aetna ‘14)
Oncology Care
Model (OCM)
MACRA
Increasing
Financial Risk
Capitation
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CMS’ ONCOLOGY CARE MODEL (OCM)
▸ Goal: incentivize providers to improve care and reduce spending for Medicare beneficiaries with cancer who receive chemotherapy
▸ Eligibility: physician practices that provide care for oncology patients undergoing chemotherapy for cancer
▸ Includes both independent medical practices and hospital-affiliated practices
▸ Term: 5-year program commenced July 1, 2016 (“Start Date”)
▸ Participation: 195 participating practices and 17 participating health plans
▸ 2018 will bring new participants
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OCM BASICS
▸ Objective: reduce the total cost of care for an OCM Beneficiary during a 6-month “Episode” to an amount below a “Target Price”
▸ 1 and 2-sided risk arrangements* ▸ 1-sided risk to June 30, 2018; option to assume 2-sided risk thereafter ▸ Deduction from “Benchmark Price” to determine Target Price: 4.0% 1-sided
risk; 2.75% 2-sided risk
▸ Payment: Traditional FFS plus PBPM plus performance payment (based on savings vs. Target Price).
▸ Practice transformation via 6 Practice Redesign Activities
▸ Metric reporting via 12 key performance indicators (KPI’s)
▸ Monitoring: Lots of monitoring by CMS/contractors, including on-site inspections *1 sided: practice must qualify for PBP by the end of the third performance year; 2-sided risk model qualifies as an APM under MACRA
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WHAT DRIVERS OF COST IN CANCER CARE DOES OCM TARGET?
Cost of chemo/cancer treatments
Poor end of life care Unnecessary hospitalizations and ED visits
SUPPORTIVE CARE FOCUS
THE ONCOLOGY CARE MODEL: 10 WAYS CAREVIVE CAN ASSIST
CANCER CENTERS MEET THE REQUIREMENTS
OCM METRICS
TREATMENT PLANNING FOCUS
THE ONCOLOGY CARE MODEL: 10 WAYS CAREVIVE CAN ASSIST
CANCER CENTERS MEET THE REQUIREMENTS
OCM METRICS
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WHAT DRIVERS OF COST IN CANCER CARE DOES OCM TARGET?
Cost of chemo/cancer treatments
Poor end of life care Unnecessary hospitalizations and ED visits
… Why??
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DATA ON SOURCES OF COST SAVINGS
Source % Cost Reduction
Drug pathways compliance 1.0% to 3.0%
Avoidable ER utilization 0.6% to 1.1%
Avoidable hospital admissions 4.0% to 7.0%
Diagnostics (imaging, lab) 0.2% to 0.5%
End-of-life care management 0.9% to 1.9%
Total potential savings 6.7% to 13.5%
(1) John D. Sprandio, MD, Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home ® Analysis of OPCMH savings conducted by third party actuary 2010. (2) How Oncologists are Bending the Cost Curve. Oncology Times. January 10, 2013. (3) Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Newcomer et. Al. Journal Oncology Practice. July 8, 2014.
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Significantly lowered cost in the case group vs. the control group
No change in overall survival between the study groups
Study: “Cost Effectiveness of Evidence-Based Treatment Guidelines for the Treatment of Non–Small-Cell Lung Cancer in the Community Setting”. Journal of Oncology Practice (ASCO Peer Reviewed Journal), 1/19/2010
1. DRUG COSTS: ADHERING TO EVIDENCE BASED GUIDELINES DECREASE COST WITHOUT NEGATIVELY IMPACTING TREATMENT EFFICACY Purpose: Evaluate the cost effectiveness of evidence-based treatment pathways for NSCLC patients
Conclusion: Results of this study suggest that treating patients according to evidence-based guidelines is a cost-effective strategy for delivering care to those with NSCLC
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DATA ON SOURCES OF COST SAVINGS
Source % Cost Reduction
Drug pathways compliance 1.0% to 3.0%
Avoidable ER utilization 0.6% to 1.1%
Avoidable hospital admissions 4.0% to 7.0%
Diagnostics (imaging, lab) 0.2% to 0.5%
End-of-life care management 0.9% to 1.9%
Total potential savings 6.7% to 13.5%
(1) John D. Sprandio, MD, Consultants in Medical Oncology & Hematology. Oncology Patient Centered Medical Home ® Analysis of OPCMH savings conducted by third party actuary 2010. (2) How Oncologists are Bending the Cost Curve. Oncology Times. January 10, 2013. (3) Changing Physician Incentives for Affordable, Quality Cancer Care: Results of an Episode Payment Model. Newcomer et. Al. Journal Oncology Practice. July 8, 2014.
About 2/3 of
the savings comes
from avoidable
hospital events.
In a BWH series, 21-28% of cancer patient ED visits were deemed avoidable (compared to 12% of general population)
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WHAT STRATEGIES REDUCE AVOIDABLE HOSPITAL EVENTS?
Symptom'monitoring'with'pa/ent1reported'outcomes'during'rou/ne'cancer'treatment:'
A'randomized'controlled'trial!
Ethan!Basch,!Allison!Deal,!Mark!Kris,!Howard!Scher,!Clifford!Hudis,!Paul!Sabba>ni,!Lauren!Rogak,!Antonia!BenneB,!Amylou!Dueck,!Thomas!Atkinson,!Joanne!Chou,!Dorothy!Dulko,!Laura!Sit,!Allison!
Barz,!Paul!Novotny,!Jeff!Sloan,!Deborah!Schrag!!!
October!2015!
RCT!Design!
21
Patients Receiving Chemotherapy for Solid Tumors at Sloan Kettering
Self-report 12 common symptoms at/between visits ! Email alerts to nurses ! Printed reports at visits
Usual care
R A N D O M I Z E
Outcomes - ER visits - Hospitalization - Duration of
chemotherapy - Quality-adjusted
survival - Overall survival - QOL at 6 months
(EuroQoL EQ-5D)
Follow for up to 1 year or until death or discontinuation of chemotherapy/hospice
N=766
Cumula>ve!Incidence!of!Hospital!Events!
22!
All patients
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Vis
iting
ER
(%) Usual care
STAR
p=0.02
Computer−experienced
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Vis
iting
ER
(%)
Usual care
STAR
p=0.16
Computer−inexperienced
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Vis
iting
ER
(%)
Usual care
STAR
p=0.02
Cumulative IncidenceAll patients
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Hos
pita
lized
(%)
Usual care
STAR
p=0.08
Computer−experienced
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Hos
pita
lized
(%)
Usual care
STAR
p=0.75
Computer−inexperienced
0 6 12 18 24 30 36
20
40
60
Months Since Enrollment
Patie
nts
Hos
pita
lized
(%)
Usual care
STAR
p=0.003
Cumulative IncidenceEmergency Room Visits 41% vs. 34% of Patients
P=0.02
Hospitalization 49% vs. 45% of Patients
P=0.08
Time receiving chemotherapy: mean 6.3 vs. 8.2 months (p=0.002)
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COST SAVINGS
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WHAT’S STOPPING US FROM TRANSLATING THESE IMPROVEMENTS IN CARE AND OUTCOMES?
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WHY AREN’T WE ROUTINELY INCORPORATING THE PATIENT VOICE?
JAMA, 2015
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And incorporating palliative care across the cancer care continuum?
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CAN TECHNOLOGY HELP?
Dr. Hesse, 6/17/16: “Automate appropriately so that clinicians can do their
work more effectively”
Can we create disruptive technology that is not simply DISRUPTIVE!?!
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CAREVIVE MISSION Bend the curves in cancer care
HOSPITAL ADMISSIONS/RE-ADMISSIONS COSTS OF CARE
# OF SURVIVORS TREATMENT ADHERENCE
ED VISITS
PATIENT QUALITY OF LIFE
CLINICAL OUTCOMES
… through technology, process, and clinical expertise
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RAPID LEARNING…..
▸ Moving towards a Rapid Learning System in Cancer Care
Abernathy AP et al. J Clin Oncol. 2010 Sep 20;28(27):4268-74
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THE CAREVIVE APPROACH
Carevive Systems develops the tools and processes to succeed in value-based models while driving patient-centered care
• Our tools help optimize the balance between care team engagement and patient self-management
• Our platform collects longitudinal data on the cancer patient experience to:
• drive better, more efficient care delivery, • improve clinical outcomes at lower costs, and
• enable analysis and reporting of the same!
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I can afford my co-pay for the treatment
recomended
Diagnosis • Treatment Plans &
Navigation • Distress Screening
Active Treatment • Distress Screening &
Navigation • Symptom Management
Survivorship • Distress Screening • Survivorship Care Plans &
Navigation
My treatment plan is aligned with my goals. I am high-risk but will follow the surveillance plan.
I know what to report & who to call I am aware of my
risks and follow up recommendations.
$$
Navigator Doctor Financial Social Chemo Rehab Radiation Nurse Counselor Worker RN Therapist Nurse Practitioner PCP
THE CAREVIVE MODEL
Coordinating Care
Incorporating the patient
voice
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HOW DID WE GET HERE? ▸ Initially, CoC accreditation was the market driver
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SURVIVORSHIP CARE DELIVERY: WHERE MY JOURNEY FROM ACADEMIA TO INDUSTRY BEGAN
Phase I: N = 13 cancer centers delivering SCPs
Stricker, C.T., Jacobs, L.A., Risendal, B….. & Palmer, SC. Journal of Cancer Survivorship 5(4): 358-370.
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PHASE 1 LIVESTRONG STUDY- PROCESS: HIGH RESOURCE BURDEN, LOW REACH
SURVIVORSHIP CARE PLANS
5(4): 358-370
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SURVIVORSHIP CARE PLANS (SCPS): “HELPFUL, BUT NOT GOOD ENOUGH”
▸ Key patient perspectives on SCPs delivered in LIVESTRONG network study ▸ Information helpful; “wish I had received it sooner”
▸ Personalization needed
▸ So much information is overwhelming
▸ “What is relevant to me?” And my concerns and symptoms?
▸ Need for more actionable information
▸ What to report, to whom
▸ How to self-manage & access relevant resources
Unpublished data; Stricker, Jacobs, Palmer et al
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TAKING A “SIMPLE IDEA” TO THE INDUSTRY SIDE
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THE “SIMPLE” IDEA
1 2
3 4
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THE “NOT SO SIMPLE” EXECUTION
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RULES ENGINE TECHNOLOGY ENABLES AUTOMATED TAILORING
▸ Carevive rules engine technology convert knowledge into a code base that is used for reasoning (i.e., we process data from a knowledge base to infer conclusions)
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ONCOLOGY EXPERT ADVISORS MAINTAIN CONTENT
Nearly 1,000 oncology experts across the United States develop tools, maintain content, and
perform research using the Carevive platform.
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CAREVIVE SYSTEMS MAINTAINS EXTENSIVE CONTENT
Professional Society Guidelines Advocacy Group Education & Resources
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HOW ARE CENTERS USING CAREVIVE?
▸ …. And what process and outcome improvements is this generating?
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HARTFORD HEALTHCARE STANDARDIZED SURVIVORSHIP CARE ACROSS MULTIPLE SITES
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…. AND HHC’S PATIENT-DRIVEN CARE PLANS IMPROVE LIKELIHOOD OF ADOPTING RECOMMENDED CARE
Web Link: https://www.carevive.com/poster-presentation-recall-uptake-survivorship-care-plan-recommendations-survonc16/
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NEXT …. OCM DROVE CARE PLANNING TO THE BEGINNING OF THE CANCER CARE CONTINUUM
SURVIVORSHIP CARE PLANS
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1! Patient information (e.g., name, date of birth, medication list, and allergies) !
2! Diagnosis, including specific tissue information, relevant biomarkers, and stage !
3! Prognosis !
4! Treatment goals (curative, life-prolonging, symptom control, palliative care) !
5! Initial plan for treatment (chemotherapy, surgery and radiation therapy)!
6! Expected response to treatment !
7! Treatment benefits/harms and management strategies!
8! Information on quality of life and a patient’s likely experience with treatment !
9! Who will take responsibility for specific aspects of a patient’s care !
10! Advance care plans!
11! Estimated total and out-of-pocket costs of cancer treatment !
12!
A plan for addressing a patient’s psychosocial health needs, including psychological, vocational, disability, legal, or financial concerns and their management !
13! Survivorship plan, including a summary of treatment and information on recommended follow- up activities and surveillance, risk reduction and health promotion activities!
OCM REQUIRES CARE PLANS* CONTAINING THE IOM 13 COMPONENTS
'
*OCM requires delivery/documentation of IOM Care Management plan once every 6 month care episode
carevive.com Carevive care plans suggest referrals and follow up actions tailored to the
individual patient’s treatment plan and risk factors
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CARE MANAGEMENT PLANS IMPROVE ADHERENCE TO QUALITY METRICS
To date, 745 treatment care plans have been delivered as part of this project at UAB and network affiliates, plus Atlanticare Cancer Institute (NJ)
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EARLY EFFORTS TO IMPLEMENT E-PRO DRIVEN SYMPTOM CARE PLANS DURING TREATMENT….
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…. MET WITH INITIAL CLINICAL ADOPTION
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… AND HIGH PATIENT SATISFACTION AND PERCEIVED PATIENT-CENTERED CARE
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…BUT WORKFLOW ENHANCEMENTS WERE REQUIRED TO ENSURE SUSTAINABILITY AND FOCUS
Mobile symptom reporting
Clinician dashboards
Clinician alerting
In q3-4 2016, 3137 surveys at Seidman alone
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… AND REQUIRED DISENTANGLING CDS & PATIENT SELF-MANAGEMENT, WHILE STILL RETAINING COMPLEMENTARITY
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WILL THESE NEW TOOLS AND PROCESSES RESULT IN ENHANCED OUTCOMES?
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OR ARE FURTHER ENHANCEMENTS NEEDED, INCLUDING RISK STRATIFICATION?
Patient-Reported Outcomes (e.g., psychosocial physical, functional)
Socioeconomic factors
Treatment (e.g., concomitant chemo/rad)
Diagnosis (e.g., metastatic disease)
Cancer center customers apply interventions in the Carevive platform to monitor higher-risk populations (e.g., increased pt. assessments, mobile access, care plan modifications, increased navigation touchpoint
Geographic factors
Other clinical variables (e.g., co-morbidities)
CAREVIVE DYNAMICALLY CATEGORIZES PATIENTS INTO RISK CATEGORIES FOR TREATMENT ADHERENCE, ED VISITS,
ADMISSIONS & 30-DAY READMISSIONSWITH EACH PATIENT SELF-ASSESSMENT
TIME
!! Moderate Risk
High Risk
Low Risk Moderate Risk
Moderate to High Risk
High Risk
Moderate to High Risk
High Risk High Risk
Low to Moderate Risk
High Risk High Risk High to Very High Risk
High Risk Moderate Risk
Low to Moderate Risk
Very High to High Risk
High Risk to Moderate
Moderate Risk
Low Risk High Risk
Low to Moderate Risk
Low Risk Low Risk Low Risk
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COMING FULL CIRCLE
▸ Moving towards a Rapid Learning System in Cancer Care
Abernathy AP et al. J Clin Oncol. 2010 Sep 20;28(27):4268-74
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CAREVIVE IS COMMITED TO IMPLEMENTATION SCIENCE & ACADEMIC-INDUSTRY PARTNERSHIPS
IN 2015-2016, WE PRESENTED >20 POSTER AND ORAL PRESENTATIONS WITH ACADEMIC AND COMMUNITY INSTITUTIONAL PARTNERS
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ONGOING AND FUTURE RESEARCH COLLABORATIONS
▸ Mobile ePRO-driven, interactive survivorship care plans (Salz/Baxis)
▸ Tablet-based mCGA frailty screening (Hurria/Mohile/Wildes)
▸ Managing toxicities of & adherence to targeted therapies in RCC (Fung)
▸ Risk stratification for exercise referrals in cancer survivors (Schmitz)
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HOW MIGHT WE WORK TOGETHER TO LEVERAGE THE ACADEMIC-INDUSTRY INTERFACE?