Providing timely access to comprehensive, integrated healthcare through a highly reliable delivery network is a major challenge for all health systems. Serving a diverse and complex enrolled Veteran population of more than 9.1 million, the Veterans Health Administration (VHA) aims to provide positive experiences for Veterans and providers through operational efficiencies/effectiveness that result from optimizing technology, data, and lessons learned from facility-specific initiatives.
The VA Pittsburgh Healthcare System (VAPHS), the largest and most complex VA healthcare system in Pennsylvania, has instituted innovative in-person and virtual comprehensive team-based care for oncology patients that uses the right modality at the right time for the right type of care. As a result of Pittsburgh VAPHS’s innovative Oncology Comprehensive Care Model (OCCM), an extremely sick veteran cancer patient living in Erie, Pa. — 128 miles away with a minimum two-hour drive — can avoid the exhausting travel to the Pittsburgh oncology “hub” while retaining a relationship with his/her oncologist and receiving appropriate, effective, timely care. Through Pittsburgh VAPHS’ OCCM, all the critical elements of a Veteran’s cancer pathway are systematically addressed in relationship to their stage of cancer and related healthcare needs.
The key features of the OCCM include:
- Cancer navigators to help guide Veterans through their cancer care journey.
- An integrated comprehensive care team.
- A variety of modalities (oral anticancer therapy, virtual cancer care, palliative care, and a survivorship clinic) to deliver the care dependent on the cancer stage and the joint decisions of the Veteran and provider as to the appropriate care. (See Figure 1).
While each element provides an opportunity for a significant positive impact to the veteran’s clinical outcomes and VHA provider decision-making, the comprehensive approach provides additional foundational, operational, and strategic benefits realization, and a potential return on investment (ROI).
Method
VHA undertook a Healthcare Failure Mode, Effect, and Impact Assessment (HFMEIA)1 to quantify the value of each OCCM component and the interrelated, cumulative impacts of the comprehensive, systematic approach. VHA used a virtual format, established a measurement plan, and structured ROI methodology (descriptive rational, operational definition, desired outcome, source systems and data, baseline measurement and follow-up measurement).
VHA completed structured information gathering sessions defining and documenting the people, business processes, technology, workflows, metrics, and measurable inputs/outputs. Data sources included the VHA Support Service Center Capital Assets Databases (VSSC), and encounter-level data collected by the Pittsburgh VAPHS.
Results
The complexities and diversity of the Veteran needs on his/her cancer journey requires an integrated, multidisciplinary team and the appropriate utilization of in-person and virtual care. (See Figure 2). The functions that virtual care can properly support within each feature of the OCCM were delineated through:
- Defining the needs of the Veteran, providers, facility, and VHA.
- Establishing a streamlined care pathway to provide effective care efficiently to Veterans. (See Figure 3).
For the Veteran, the cancer navigation is the first step in the oncology care pathway and a critical success factor in maximizing efficiencies in care downstream. Pittsburgh VAHC cancer nurse navigators quarterback the consult process, working with schedulers to assure a Veteran-centric focus (see Table 1) and continuity of care during transitions between primary care (PC) and specialty oncology care (SC), including related ancillary services.
All new Veteran cases are referred to oncology through a consult order. Cancer navigators prioritize cases and determine the viability of the consult appointment and modality (face-to-face versus virtual). The consult order template was redesigned to simplify the requirements for prerequisite workups, including a separate consult specifically for the cancer navigator, to proactively identify, collect and scan any outside medical records associated with the case into the EHR for the oncology provider.
Through coordinating with the triaging oncology providers, navigators expedite the ability for providers to evaluate and determine if the case is ready to be accepted, ensuring cases referred to specialty care are complete with all relevant records, pathologies, images and labs. Veterans also saw a performance improvement of 0.08 between FY 2015 and 2018 in obtaining test results, which potentially impacts Veteran satisfaction and clinical outcomes. (See Table 1).
If the case is not appropriate, the triaging oncology provider returns the consult through an e-consult order with recommendations and guidance on treatment and follow-up to the ordering provider. If the Veteran’s case is accepted, the navigator provides a warm introduction through a telephone encounter, informing the Veteran of expectations for his/her first appointment and screening for necessary care coordination activities, which can reduce anxiety related to diagnosis and treatment by ensuring the Veteran is informed of his/her options. By ensuring the prerequisite requirements to submit a consult are completed, the cancer navigator reduces the burden on referring and triage providers, removes barriers to cancer care, reduces specialty care revisits, and lessens the additional travel times for Veterans to complete necessary prework, while expediting the time to confirm diagnoses and initiate treatment.
Once the oncology team has accepted the Veteran, he/she completes his/her in-person first oncologist appointment at the Pittsburgh VAPHS; however, depending on the severity of the diagnosis and location of the Veteran, a virtual appointment may be provided to reduce travel burdens and expedite the initiation of treatment. The oncologist develops the treatment plan, which has been standardized as a note type in the EHR, providing all team members across all sites with a uniform view of the designated treatment and complete care. If the Veteran needs outpatient care, the Veteran may be an appropriate candidate for oral anticancer therapy (which accounts for nearly half of all treatments provided at Pittsburgh VAPHS3).
For Veterans who can appropriately be treated through oral anticancer therapy, the Pittsburgh VAPHS oral anticancer therapy clinic develops a treatment plan, provides the initial Veteran education, and engages the relevant care team members (dietician, social worker, psychiatrist, etc.). The clinic includes a hematologist/oncologist and is run by a specialized oncology care board certified PharmD, who has full practice of authority to follow up with the Veteran through virtual care modalities. The PharmD reviews, procures, and mails oral anticancer therapy medications directly to the Veteran or writes an order for the Veteran, screens for adverse reactions or side effects from treatment, and evaluates Veteran treatment compliance in real time. PharmD encounters increased from 1,001 in FY18 to 4,085 in FY21.4
Since a Veteran treated via oral anticancer therapy is empaneled to the PharmD, the Pittsburgh oncologist can focus his/her time in the physical or virtual clinic on new cases, developing/updating treatment plans, and following up on Veterans who are not responding well to their treatments. When necessary, the PharmD leverages the EHR, conferencing software, and telephone encounters to communicate with the oncology care team across the spoke sites, signing off on or recommending adjustments to the dosing or treatment plan as an addendum to the standardized treatment plan note type, which is then reviewed and updated by the oncologist. The oral cancer therapy approach minimizes the need for the Veteran to travel and mitigates negative physical and psychological side effects from treatments by providing the care the Veteran deserves, in the comfort of his/her own home, while enhancing medication compliance and reducing costs to the system.
For a Veteran determined not to be a candidate for oral anticancer therapy, the OCCM affords the Veteran with a virtual cancer care clinic option. The center piece of the integrated care model, the virtual cancer clinic delivers a hybrid telehealth, telephone, and face-to-face care experience by providing remote IV chemotherapy administrations at the Veteran’s home “spoke” site (Erie and Altoona). The Pittsburgh oncologist, who reviews the labs, images and other information provided by the oncology nurse team from the spoke site, screens the Veteran through a telehealth encounter prior to the Veteran’s chemotherapy administration at the spoke site.
Once the Veteran provides consent to proceed with treatment, the Pittsburgh oncologist signs off on the treatment plan and the pharmacist at the spoke site is alerted to compound the chemotherapy through the EHR; the nursing team then administers the IV chemotherapy to the Veteran. To ensure a safe environment for the Veteran since the oncologist is not physically present, there is a rapid response team onsite prepared to stabilize the Veteran and ensure expedient care to mitigate potential risks to the Veteran’s health. Even though the oncologist is hundreds of miles away, the oncologist can effectively follow the Veteran virtually through telehealth with a nurse or technician present.
The appropriate use of the virtual cancer care clinic visits within the Pittsburgh OCCM reduced the financial burden and time commitment for the Veteran, providers, and VHA health system travel programs due to distance, time, and costs, while enhancing the Veteran’s satisfaction by delivering care closer to home. The VHA Travel Impact Model indicates a potential total commute time savings from FY18 to FY21 for Altoona Veterans of 8,150 hours at a potential cost of $283,744.70; for Erie Veterans, the total potential savings is 2,908 hours at $108,078.28 (See Table 2).
The OCCM improves multidisciplinary access to cancer care in rural areas, creating new specialty-specific healthcare jobs. It secures safe access to cancer treatment and management with onsite care teams accountable for emergent scenarios, while the oncologist at the hub is available virtually to provide support and consultation. Importantly, it removes geographical barriers to care delivery while maintaining the Veteran’s primary relationship and continuity with their oncologist/care team and ensuring the Veteran is maintaining appropriate treatment intervals, potentially reducing compounded/dispensed treatments that are not utilized.
An outcome of the OCCM is that the geographic reach of Pittsburgh VAPHS has vastly expanded. From FY18 to FY21, the number of completed oncology consults for Pittsburgh VAPHS increased from 2,122 to 2,429 (14.5%), while the number of Pittsburgh-to-Altoona completed consults increased from 57 to 283 and Pittsburgh-to-Erie from 279 to 446.6
Even during the COVID-19 pandemic, oncology encounters remained relatively the same for the combination of Pittsburgh VAPHS, Erie, and Altoona sites, but the Altoona encounter location showed a threefold increase. The mode of delivery changed for all sites:
- Pittsburgh VAPHS face-to-face encounters decreased from 6,613 (FY18) to 5,045 (FY21), but the use of VA Video Connect (VVC) increased from zero to 250 (FY18-FY21), and the use of CVT Patient Site rose from 313 to 1,534 (FY18-FY21).
- The total number of face-to-face encounters remained miniscule (two in FY18 and one in FY21) at Altoona, but the use of VVC/CVT increased from 299 to 901.
- Erie’s face-to-face encounters dropped from 739 to 187 (FY18-FY21); however, VVC/CVT use increased from zero to 605 (FY18-FY21). (See Table 3).
The change in delivery modality during COVID-19 allowed for the continuation of care and limited the risk to harm for cancer patient care.
At the end stages of cancer care treatments, the pathway for the Veteran diverges to either survivorship or the need for palliative care. The early integration of palliative care services — which includes symptom management from the side effects of treatment, pain management, and hospice — is dependent on virtual care modalities for success. The Pittsburgh palliative care team delivers care to Veterans treated at hub and spoke sites and in conjunction with the Veteran’s regular follow-up visit with his/her oncologist, maximizing appointment times and convenience for the veteran. Most of the palliative care is provided through virtual visits, which benefits a Veteran with advanced stages of cancer, in the most pain, with the highest toxicities, and least ability to travel to a medical center with any level of comfort.
Palliative care integrated into the comprehensive care model improves Veteran, family, and caregiver satisfaction by ensuring the goals of the Veteran’s care are met based on the preferences in his/her advanced directives, while reducing costs through decreasing ICU/ER/inpatient hospital admissions and chemotherapy treatments closer to the end of life. It also improves the Veteran’s quality of life by coordinating Veteran support services and proactively engaging the Veteran in the management of his/her pain, anxiety, depression, and appetite. In addition, it reduces the physical and psychological burdens of treatments that are no longer improving or stabilizing the Veteran’s condition and facilitates the Veteran’s end of life at home in a comfortable setting.8
The second pathway, the Pittsburgh survivorship clinic, is designed to deal with longer-term impacts of care for Veterans who have a diagnosis of stage I, II or III cancer and have completed curative treatment for an initial cancer event in VHA within the last six months, while not currently on hormone therapy.9 The Veteran meets with a survivorship provider to develop a treatment summary, a survivorship care plan with goals of care, and a whole health education program. According to one Veteran, “I learned a lot about the cancer I had, what is out there to help me and how to be on the lookout for it coming back.10
The survivorship provider shares relevant information with the Veteran’s PC provider and refers the Veteran to additional clinics or specialties to address other health issues, as needed. During COVID-19, the survivorship provider used telephone or video. The survivorship provider keeps the entire care team, including the Veteran and family, informed of the Veteran’s status and condition through a cosigned summary note and surveillance plan that documents the care lifecycle from diagnosis to the completion of treatment, including follow-up care intervals. Some of the benefits realized by the Veteran include:
- A completed survivorship summary of the diagnosis and the goal of the treatment
- Help with long-term side effects including fatigue, nausea, rash and sexual disfunction
- Linkage to supportive resources in the community and in the VA system, including patient and caregiver support groups
- Follow-up for up to five years.11
While each component of the Pittsburgh OCCM provides a value to the Veteran, VAPHS and VHA, the integration and alignment of the comprehensive strategy provides streamlined care, timely access, and continuity of care for the Veteran more efficiently and effectively. While preserving the personalized face-to-face interactions between the provider and the Veteran, it operationalizes a multidisciplinary, team-based approach to care and provides the Veteran with a choice of where to receive care without compromising quality or safety.
Discussion
Healthcare administrators must find a way to optimize the appropriate use of virtual care, while assuring patient safety and quality are maintained. This requires evaluating the life cycle needs of the patient, specialty by specialty, in a comprehensive approach (such as the OCCM) that facilitates fast and reliable clinical decision-making and assures the appropriate modality of delivery at the appropriate time to assure the right care.
The VAPHS OCCM, which has improved access to multidisciplinary cancer care and provided safe access to cancer treatment and management, establishes a comprehensive prototype that can be used by other specialties. Through the model, the same care processes have been maintained regardless of where the Veteran is receiving care, including retaining a relationship with his/her oncologist. It has created new specialty-specific healthcare jobs in rural areas, which provides a benefit realization for the rural community as well as the VA. It provides highly reliable, Veteran-centric care that optimizes the use of virtual care within a process that institutionalizes timely access, patient safety, accountability and provides a potential ROI.
Conclusion
Through the Pittsburgh OCCM, the VA has streamlined care by systematically addressing all the critical elements of a Veteran’s cancer pathway, including cancer navigation, oral anticancer therapy, virtual cancer care, palliative care, and survivorship. The model uses a Veteran-centric strategy that considers the appropriate care and modality of delivery, and provides strategic, operational, and foundational benefits realization and ROI for the Veteran, provider, and healthcare system. What VA has accomplished through this model for oncology patients is transferrable to the private market for cancer patients to address the life cycle of their illness.
Notes:
1. VHA National Center for Patient Safety. “Healthcare Failure Mode and Effect Analysis (HFMEA).” U.S. Department of Veterans Affairs. Available from: bit.ly/3NAz5ap.
2. Figure courtesy of VHA Support Service Center Capital Assets Databases (VSSC).
3. Pittsburgh VAPHS data, VHA internal documents.
4. Pittsburgh VAPHS data, VSSC, VHA internal documents.
5. Estimates based on veteran encounters over an eight-month period in Pittsburgh as published in Jiang, et al. “Telehealth for Cancer Care in Veterans: Opportunities and Challenges Revealed by COVID.” JCO Oncology Practice, 2021 17:1, 22-29. doi: 10.1200/OP.20.00520.
6. Pittsburgh VAPHS data, VSSC, VHA internal documents.
7. VHA VSSC, 316 Oncology.
8. Pittsburgh VAPHS data, VHA internal documents.
9. “Cancer Survivorship Program.” Veterans Connect, Issue 11, 2020, pg. 5. Available from: bit.ly/3sRTKia.
10. Ibid.
11. Pittsburgh VAPHS data, VHA internal documents.
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