Oncology Care Model

CMS Practice Requirements

  1. Provide and attest to 24 hours a day, 7 days a week patient access to an appropriate clinician who has real-time access to practice’s medical records (SPAC systems capture and provides care coordination via its mobile application and patient support staff for 24 hours a day.)

  2. Attestation and use of ONC-certified electronic health records (EHRs).

  3. Utilize data for continuous quality improvement (SPAC captures real time patient symptoms).

  4. Provide core functions of patient navigation (SPAC makes patient navigation and management simple and helps automate the process).

  1. Document a care plan that contains the 13 components in the Institute of Medicine Care Management Plan (SPAC makes the care plan access for 24/7 from any EMR) Practice has to develop the care plan for each patient see below:

    2. Appendix A: Components of the Institute of Medicine Care Management Plan13

    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 and proposed duration, including specific chemotherapy drug names, doses, and schedule as well as surgery and radiation therapy (if applicable)

    6. Expected response to treatment

    7. Treatment benefits and harms, including common and rare toxicities and how to manage these toxicities, as well as short-term and late effects of treatment

    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 (e.g., the cancer care team, the primary care/geriatrics care team, or other care teams)

    10. Advance care plans, including advanced directives and other legal documents

    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, as well as risk reduction and health promotion activities

  1. Treat patients with therapies consistent with nationally recognized clinical guidelines see below:

    2. Appendix B: National Cancer Institute Sample Patient Navigation Activities 14

    1. Coordinating appointments with providers to ensure timely delivery of diagnostic and treatment services

    2. Maintaining communication with patients, survivors, families, and the health care providers to monitor patient satisfaction with the cancer care experience

    3. Ensuring that appropriate medical records are available at scheduled appointments

    4. Arranging language translation or interpretation services

    5. Facilitating financial support and helping with paperwork

    6. Arranging transportation and/or child/elder care

    7. Facilitating linkages to follow-up services

    8. Community outreach

    9. Providing access to clinical trials, and

    10. Building partnerships with local agencies and groups (e.g., referrals to other services and/or cancer survivor support groups).