Background: The burden of acute care among cancer patients, estimated to exceed $70B by 2020, represents ~50% of all costs of advanced cancer care and accounts for 70% of nationwide regional variation in these costs. The Centers for Medicare and Medicaid Services proposed value-driven Rule OP-35 includes a mandate to reduce acute care use among Oncology patients. Emergency Departments (ED) are the gateway to much acute care use and their 60% oncology patient admit rates are more than double general rates. Keeping oncologic urgencies and emergencies out of the ED has the potential to increase value for Oncology care delivery.
Purpose: To launch a dedicated Oncology Urgent Care clinic that offers same-day treatment for oncologic urgencies/emergencies as well as unplanned supportive care needs and, where necessary, facilitate direct admission to the inpatient service.
Description: The Smilow Cancer Hospital (SCH) Oncology Extended Care Clinic (OECC) is a 6-bed urgent care center dedicated to serving the >10,000 active analytic cases of the SCH Care Network that includes a tertiary academic center and 10 Connecticut-wide community-based practices. The OECC operates 365 days from 7 am – 11 pm with primary staffing by 4 Advanced Practice Providers, 5 Registered Nurses and an ABIM-certified Hospitalist Attending in consultation with the Primary Oncologist. Situated within the hospital, the OECC can access resources typically restricted to inpatients including same-day subspecialty consults, STAT diagnostic testing and care coordination. The OECC can also trigger a Rapid Response Team (RRT) which enables caring for high-acuity patients; only cardio/cerebrovascular urgencies, respiratory collapse and shock are outside the scope of practice.During the first 13 months of operation, the OECC staffed 2855 visits across 1570 unique patients, including 1089 with solid tumors, 449 with liquid tumors and 32 patients with benign hematologic needs. While 953 patients visited the OECC once, 145 had ≥4 encounters. Gastrointestinal Oncology (256 patients, 459 visits), Leukemia (170 patients, 374 visits) and Thoracic Oncology (150 patients, 255 visits) most frequented the OECC. Altogether, 863 (30.2%) visits were for clinic overflow (e.g., transfusion) and 1994 visits were for urgent indications. Urgent care visits resulted in a 43.3% admission rate with genitourinary cancer (OR=1.91; 95% CI: 1.07-3.41), head and neck cancer (OR=3.93; 95% CI: 2.26-6.92) and bone marrow transplant (OR=2.15; 95% CI: 1.19-3.88) independently associated with admission. Common indications for admission included intractable pain (102/151 visits, 67.5%), neutropenic fever (94/101 visits, 93.1%) and bowel obstruction (30/41 visits, 73.2%).
Conclusions: The OECC shows a substantial reduction in overall admission rates in the urgent care setting compared with historic levels. Determination of impact on Smilow patient ED presentation rates and on overall cost of care are ongoing.