Background: The purpose of the Oncology Care Model is to improve quality and reduce cost through practice transformation. A foundational tenant is to reduce avoidable ER visits and hospitalizations. In anticipation of being an OCM participant, we instituted a multidimensional campaign designed to meet these objectives. Methods: Prior Actions:

Established phone triage unit.

After-hours and weekend call.

Instituted weekend urgent care.

Year One:

Improved education provided by nurse navigators and APPs prior to start of treatment (OCM Treatment Planning visit).

Implemented triage pathways: 38 symptom and 27 follow-up pathways (modified COME HOME, Barbara McAneny, M.D.).

Proactive symptoms follow-up calls to help circumvent emergent admissions.

Increased APP staffing to provide blocked time slots for same day patient visits w/o schedule disruptions.

Initiated “Call Us Early – Call Us First” campaign. Incorporated verbal and/or written instructions at all patient touch points, emphasizing patient’s responsibility to call before going to the emergency room.

Results: Based on data from the Chronic Condition Warehouse, as provided by CMS, we were successful at reducing the acute care admissions rate by 16 percent. Conclusions: By implementing a cost efficient, reproducible, and scalable campaign targeting ER avoidance and hospitalizations, we were able to decrease hospital admissions. Reported Medicare savings amounted to nearly $798,000 in inpatient cost per quarter over 1,600 patients.

	Baseline Jan ’16 – Mar ‘16	Year One Jul ’16 – Jun ‘17	Year One Benchmark (Risk Cohort)
Patients per Quarter	1,722	1,600	-
Mean Patient Risk Score	2.999	3.000	> 2.724
Admissions per 100 Patients, per Quarter	27.0	22.6	25.9
Cost per Admission Event	11,122	11,106	-
Inpatient Cost per Patient, per Quarter	3,003	2,505	-