Stakeholders in oncology increasingly recognize that certain inequalities in cancer care are linked to Social Determinants of Health (SDoH), including level of education, occupation, income, sex, race, ethnicity, place of residence and social support presence. [1] It is encouraging to see this growing acknowledgement, as these factors have been strongly linked to cancer prevalence, outcomes, and rates of morbidity, mortality and survivorship. In turn, these issues can impact many aspects of cancer treatment, including decision-making and barriers to cancer care.

In fact, the American Cancer Society is making the case for and emphasizing the importance of health equity, stating, “Cancer is a disease that affects everyone, but it doesn’t affect everyone equally.” [2] Studies show that patients with a lower economic and social status, including racial and ethnic minorities and other marginalized populations, experience lower quality health care. [3]

Defining Health Equity
According to the CDC, health equity is when everyone has an equal opportunity to prevent cancer, find it early, and get proper treatment and follow-up treatment is completed. [4] Everyone deserves to be treated equally to eliminate cancer disparities, from prevention and screening through treatment that can help improve the health care disparities seen in cancer care.

Consequences of the factors embedded in the SDoH create negative financial impacts for hospitals and health systems, particularly for costly and complicated patient medical conditions such as cancer. Unplanned and avoidable ER visits and inpatient admissions disrupt care delivery and continue to be associated with a significant proportion of healthcare costs.

Medicare reports that roughly two million patients are readmitted each year at a cost of US $26 billion, and officials estimate US $17 billion of that comes from potentially avoidable readmissions. [5] Research further demonstrates that minority and other vulnerable populations are more likely to be readmitted for chronic conditions, including cancer, within 30 days of discharge. [6][7] Findings showed that while not all readmissions are avoidable, a portion of unplanned readmissions may be prevented by addressing the barriers patients face before, during and after admission, discharge and continuing treatment.

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Transitioning Care
By definition, SDoH risk factors are particularized and exist at the individual patient level and within their specific community. These include a wide variety of practical, emotional, informational, financial and cultural issues, and many of these concerns are outside of the typical health system’s visibility and control. Actually, nearly 80 percent of a patient’s variable risk is tied to social, environmental, and behavioral factors outside the health system or care episode.[8]

Transitioning care from the hospital or cancer care facility to the home setting raises many challenges that need meaningful solutions. In this shift, since patients will be spending less time in a traditional clinical setting, it becomes more important than ever to create and administer programs that work to address whole person health. Oncology patients experiencing SDoH risk factors require amplified levels of monitoring beyond the hospital’s facilities to remotely address their whole spectrum of health and socioeconomic condition.

Supporting the Enhancing Oncology Model (EOM)
The Centers for Medicare & Medicaid Services (CMS) have introduced a significant initiative to test how to improve health care providers’ ability to deliver care centered around patients, consider patients’ unique needs, and deliver cancer care in a way that will generate the best possible patient outcomes.

The Enhancing Oncology Model (EOM) aims to drive transformation and improve care coordination in oncology care by preserving and enhancing the quality of care furnished to beneficiaries undergoing treatment for cancer while reducing program spending under Medicare fee-for-service. [9] Under EOM, participating oncology practices will take on financial and performance accountability for episodes of care surrounding systemic chemotherapy administration to patients with common cancer types. EOM is a 5-year voluntary model, which began on July 1, 2016 that aims to improve quality and reduce costs through payment incentives and required participant redesign activities.[9]

To further illustrate the importance of health equity, EOM contains the following number of references: 48 to disparities, 40 to health equity, 31 to patient navigation, 18 to care management and 5 to SDoH. Section IV. Health Equity Strategy (page 13-17) within the RFA details the program goals and requirements. In addition, the EOM model release statement represented at least the second major release by CMS that emphasized the importance of “health related social needs”.

As part of the use of data for quality improvement, participants in EOM submit health equity plans to CMS and detail their evidence-based strategies to mitigate health disparities identified within their beneficiary populations.

Under EOM, participants are incentivized to consider the whole patient and engage with them proactively, during and between appointments. EOM participants are required to implement participant redesign activities, including 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes (ePROs), screening for health-related social needs, use of data for quality improvement and use of certified electronic health record technology. [add reference to new fact sheet that allows practices to use voice to gather patient reported outcomes]

Care Guidance Solution
Further validation of the importance of an equitable path forward for all cancer patients comes from the venerable American Association for Cancer Research (AACR). They recommend the use of patient advocates and navigators who can resolve SDoH-related disparities, the vast majority of which are non-medical in nature. Underscoring this recommendation is an article posted by the National Academy of Medicine stating: “As a determinant of health, medical care is insufficient for ensuring better health outcomes. Medical care is estimated to account for only 10-20 percent of the modifiable contributors to healthy outcomes for a population. The other 80 to 90 percent are sometimes broadly called the SDoH: health-related behaviors, socioeconomic factors, and environmental factors.” [10]

Care guidance is taking on increased importance in the healthcare industry, particularly for cancer patients. This approach is built on peer-to-patient relationships that identify and resolve non-clinical barriers, or escalate clinical issues to the proper clinical and social service teams, and eliminate the consequences of these disparities which are even more pronounced among lower-income, minority and rural populations. Peer-to-patient relationships can have important impacts in reducing levels of intimidation, confusion and anxiety that are unfortunately present for many under-resourced patients.

Hospitals, health systems and provider organizations can positively improve health equity and drive associated financial and operational improvements by utilizing this unique, proven approach of employing care guides in cancer care. [11] Promptly addressing the physical, practical, emotional, informational, cultural, spiritual and familial barriers that impact patients both improves clinical quality and decreases cost.

A highly structured care guidance platform, to facilitate scalable and repeatable interactions between the care guide and the patient, is critical to not only the success of the peer-to-patient relationship, but also to capture and communicate relevant data back to healthcare organizations, such as those data elements required under the EOM. A properly designed care guidance platform will help guide a variety of conversations and barrier resolutions completely distinct from clinical issues, and this design further facilitates the effectiveness of non-clinically trained care guides. This is also important to creating a true peer-to-patient relationship. Electronic Health Records (EHR) generally lack structured workflows for solving non-clinical issues and barriers, and a well-designed care guidance platform can solve this problem while making data transfer to the EHR — where the clinical teams spend their time working — easier and more transparent.

As a result, the guidance platform becomes critically important for capturing SDoH data and disparity related barrier resolution and facilitating operational improvement by seamlessly escalating clinically relevant information while delivering SDoH insights for each patient population.

Opportunity for Incentive Payments
The EOM model aims to improve quality and reduce costs through payment incentives that reward participant redesign activities. [9] Care guidance aligns with CMS designed EOM to improve health care providers’ ability to deliver care centered around patients, consider patients’ unique needs, and deliver cancer care in a way that will generate the best possible patient outcomes.

Care guidance is clearly an opportunity for participants to earn payment incentives. Under EOM, participants are incentivized to consider the whole patient and engage with them proactively, during and between appointments. EOM participants are required to implement participant redesign activities, including 24/7 access to care, patient navigation, care planning, use of evidence-based guidelines, use of electronic Patient Reported Outcomes (ePROs), screening for health-related social needs, use of data for quality improvement, and use of certified electronic health record technology.

As part of the use of data for quality improvement, a reliable care guidance solution enables participants to submit health equity plans to CMS, where EOM participants will detail their evidence-based strategies to mitigate health disparities identified within their beneficiary populations.

Furthermore, a care guidance solution conforms with EOM two-part payment structure for participants to incentivize the provision of Enhanced Services while creating incentives to reduce avoidable costs and utilization and improve care quality. This also supports participants in their potential to earn a performance-based payment (PBP) or owe CMS a performance-based recoupment (PBR).

Value of Care Guidance
The use of care guides in cancer care, as an extension beyond the hospital walls and inside the patient’s home, is validated. Studies have produced a robust evidence base demonstrating that Hospital at Home (HaH) care provides high-quality, safe, equitable, and effective care. [12][13] Compared with traditional hospital care, patient and family care experience is better while complications and costs are lower.

Greater patient adherence has been observed though care guidance scoring, with increases in wellness visits, reductions in missed appointments and increases in target surgeries, while also optimizing patient experiences through improved HCAHPS scores. Navigated patients are significantly less likely to use acute care services (ER, inpatient admission, ICU stays), and are therefore less expensive to Value-Based Care participants. Equally important, navigated patients report higher levels of satisfaction with their care, meaning that care guidance is a critical component in achieving the Institute for Healthcare Improvement’s Triple Aim.[14]

Care guidance is aligned with the goals of the newly formed National Alliance to Impact the Social Determinants of Health (NASDOH), a national advocacy organization of healthcare industry stakeholders — both payers and providers — that aims to focus national attention on SDoH to improve health and well-being while reducing long term spending on healthcare.

Additionally, care guidance is tied to optimal HEDIS scores that advance health equity. Published by the National Committee for Quality Assurance (NCQA) for Social Need Screening and Intervention (SNS-E). Care guidance implements a multi-point Solution as a Service model to positively impact HEDIS Metrics, CAHPS scores and Medicare Stars Ratings through outbound interactions and the active identification and resolution of healthcare barriers related to SDoH.

According to NCQA leaders, these new measures are part of an organization-wide effort to advance health equity and encourage health plans to assess and address the food, housing and transportation needs of their member populations. Health plans can identify specific needs and connect members with the resources necessary to address unmet social needs.

Support of Critical Nursing Shortages
The COVID-19 pandemic posed unprecedented challenges to our nation’s healthcare system. A surge on hospitals, from emergency rooms to intensive care units, revealed vulnerabilities in clinical processes and over-stressed nursing and clinical care teams, resulting in shortages of registered nurses shortages among health systems that the American Nurses Association (ANA) is calling a national crisis.[15][16]

According to experts, an estimated 80 percent of a person’s health is determined by nonclinical factors. Nurses are often tasked with addressing these issues, including scheduling follow-up visits, ensuring transportation and attending to a myriad of barriers to care attributed to SDoH.[17] It is documented that anywhere from 18-23% of patient issues are recorded as clinical, physical barriers while the other 77-82% come from practical, non-clinical barriers.[18]

Care guidance supports clinical nursing teams — freeing up critical time and capacity to focus on clinical issues, which allows nurses to work closer to the top of their license. This proven approach lowers total cost of care for payers and raises quality metrics in VBC arrangements. Care guides provided an innovative solution to clinical staff and resource shortages, maximizing efficiency of hospital nursing teams. In fact, moving non-clinical tasks from the day-to-day work of nurses has been associated with increased job satisfaction for the nurses who are better able to work on issues for which they trained and which they prefer. This is where the value of care guides as an extension of the hospital’s clinical team is fully realized.

Technology-Assisted Connected Care with Human-Touch
Care guidance programs, which are successfully being applied to cancer care, is an example for health systems nationwide to deploy as a proven, comprehensive and peer-to-patient—powered approach to care navigation.

A successful care guidance program should include:

  • The right mix of people and technology working together to provide personalized guidance that addresses the needs of all patients, improves individual health outcomes and enhances their satisfaction.
  • Human Patient Monitoring (HPM) provides the high-tech capabilities of Remote Patient Monitoring (RPM), driven by the human touch.
  • Complementing the role of analytics to help identify probable risk, technology can facilitate communication — although neither approach (pure technology or pure analytics) can establish the essential personalized, peer-to-patient relationship that leads to real, meaningful patient activation.

Care guidance can provide much needed assistance, with AI-enabled, and data-driven tools that can offer engagement and manage patient spending through right-track alignment across the entire care journey. The collection of data is also crucial in informing care guidance to clinical and non-clinical staff and tech-enabled care guidance. Connected care shows promising results. Representative outcomes show resolution of patient barriers and reductions in cost of care, in patient ‘no-show’ rates and readmission rates for in-patient services.

Implementing Care Guidance in Value-Based Care
Until now, there has been a lack of coordination of investment in these “upstream” issues, and lack of a standardized approach for addressing SDoH in community and clinical settings. In order to transform how healthcare providers are reimbursed for services rendered, CMS has introduced an array of Value-Based Care (VBC) models, such as the Medicare Shared Savings Program, Next Generation ACO Model, and Pioneer Accountable Care Organization (ACO) Model. Private payers have, in turn, adopted similar models of accountable VBC.

While the traditional fee-for-service reimbursement model promoted the quantity of services, federal officials have proposed several reimbursement programs that reward healthcare providers for the quality of care that they give to patients. VBC seeks to advance the triple aim of providing better care for individuals, improving population health management strategies and reducing healthcare costs.
In more basic terms, VBC models center on patient outcomes and how well healthcare providers can improve quality of care based on specific measures, such as reducing hospital readmissions and improving preventative care. These are clearly aligned goals and objectives of care guidance programs.

[1] What are social determinants of health? Office of Disease Prevention and Health Promotion/U.S. Department of Health and Human Services. Online. Last accesses on January 11, 2023
[2] Making for and emphasizing the importance of health equity. American Cancer Society. Online. Last accesses on January 23, 2023.
[3] Ndugga N, and Artiga S. Disparities in Health and Health Care: 5 Key Questions and Answers. Online Kaiser Family Foundation, May 11, 2021.
[4] Equity in Cancer Prevention and Control. Health Equity in Cancer. Centers for Disease control and prevention (CDC) Online. Last accesses on January 11, 2023.
[5] Value-Based Care Approach to Reducing Readmissions: An Enterprise-Wide Care Management Team Sport. Healthlink Advisors. Online. Last accesses on January 11, 2023.
[6] Guide to Reducing Disparities in Readmissions (August 2018). Centers for Medicare & Medicaid Services. Online.  Last accesses on January 11, 2023.
[7] Pituskin E. Cancer as a new chronic disease: Oncology nursing in the 21st Century. Can Oncol Nurs J. 2022 Feb 1;32(1):87-92. PMID: 35280062; PMCID: PMC8849169.
[8] Deng X and Shih P. Social Determinants of Health: The Unaddressed Variable Accounting for 80% of Health Outcomes. CareJourney. Online. Last accessed on January 11, 2023
[9] Enhancing Oncology Model (EOM). Centers for Medicare & Medicaid Services. Online. Last accessed on January 11, 2023.
[10] Magnan S. Social Determinants of Health 101 for Health Care: Five Plus Five. October 9, 2017 Online. Last accessed on January 11, 2023.
[11] Rocque GB, Pisu M, Jackson BE, Kvale EA, Demark-Wahnefried W, Martin MY, Meneses K, Li Y, Taylor RA, Acemgil A, Williams CP, Lisovicz N, Fouad M, Kenzik KM, Partridge EE; Patient Care Connect Group. Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer. JAMA Oncol. 2017 Jun 1;3(6):817-825. doi: 10.1001/jamaoncol.2016.6307. PMID: 28125760; PMCID: PMC5540048.
[12] Leff B, Milstein A. What We Learned From The Acute Hospital Care At Home Waiver—And What We Still Don’t Know, Health Affairs Forefront, June 27, 2022. DOI: 10.1377/forefront.20220623.684203
[13] Siu AL, Zhao D, Bollens-Lund E, Lubetsky S, Schiller G, Saenger P, Ornstein KA, Federman AD, DeCherrie LV, Leff B. Health equity in Hospital at Home: Outcomes for economically disadvantaged and non-disadvantaged patients. J Am Geriatr Soc. 2022 Jul;70(7):2153-2156. doi: 10.1111/jgs.17759. Epub 2022 Apr 1. PMID: 35363372; PMCID: PMC9283257
[14] An overview of the IHI Triple Aim. Institute for Healthcare Improvement. Online. Last accessed on January 11, 2023.
[15] Ochieng N , Chidambaram P, and Musumeci M. Nursing Facility Staffing Shortages During the COVID-19 Pandemic. Online. Kaiser Family Foundation. April 4, 2022
[16] ANA Urges US Department of Health and Human Services to Declare Nurse Staffing Shortage a National Crisis), American Nurses Association (ANA). Online Press Release. September 1, 2021. Last accesses on January 11, 2023.
[17] Fisher E, Akiya K, Wells A, Li Y, Peck C, Pagán JA. Working Across Sectors To Improve Health For Older People: The Community Care Connections Program, Health Affairs Blog, January 30, 2020. DOI: 10.1377/hblog20200129.627279
[18] Author’s proprietary data; supporting documentation available upon request.

Featured image: Rural healthcare providers face a host of unique challenges that force physicians, nurses, and hospital administrators to think creatively in order to deliver the highest quality care possible to patients.  Photo courtesy: © 2016 – 2023 Fotolia/Adobe. Used with permission.

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