Collaboration: Key to oncology program

Vendor, health plan CMs work together

When Blue Cross and Blue Shield of Missouri negotiated a contract with Quality Oncology to handle utilization management and case management services care for its members with cancer, the health plan insisted that the vendor use the insurer’s system so the in-house staff would have instant access to patient data.

"The fact that everybody is entering information into the same system keeps everybody informed so there is no disconnect or duplication," says Sharon Hoffarth, MD, medical director for quality management who supervised the implementation of the oncology management program.

Under the terms of the contract, the Quality Oncology nurses work with the member, the member’s family, and the member’s provider from the time a diagnosis of cancer is suspected through the active treatment, treatment for recurrences, and hospice care when necessary. They also work closely with the patient’s regular case manager.

"This way, we make sure there aren’t any gaps in service, duplication, overlap, or mixed signals," Hoffarth says.

Blue Cross and Blue Shield of Missouri’s in-house case managers coordinate with the Quality Oncology case managers on patients who have other chronic conditions, such as diabetes or heart disease.

For instance, if a diabetic tells the oncology case manager about problems related to an insulin pump, the oncology case manager has access to data that enables him or her to locate the health plan case manager who is managing the diabetes and get the problem taken care of immediately.

Since they enter their nursing notes into the Blue Cross and Blue Shield electronic data system, the in-house case managers know what is going on with the patients. When the oncology case manager determines that the patient no longer needs services relative to cancer care, the health plan case manager take over.

The arrangement is seamless for members, providers, and staff.

The Quality Oncology nurse-case managers and physician advisors are linked to the insurer’s computer and telephone system. When a physician calls the certification number, a prompt will tell him or her to enter a number for oncology. The physician then will be linked directly to the Quality Oncology certification nurse.

The data entered at Quality Oncology automatically becomes part of the case records at Blue Cross Blue Shield.

"Our concurrent review certification nurses work directly with the Quality Oncology nurses. They call back and forth all the time about any members hospitalized for diagnostic work-ups or treatment for cancer," Hoffarth says.

Since the insurer’s concurrent review nurses follow the members’ care during hospitalization, they act as eyes and ears for the Quality Oncology case managers, alerting them to what they may expect.

The oncology certification nurses are the same nurses who manage on the case management side so they know everything that happens on the inpatient treatment side and, once their outpatient treatment starts, there is no transition for the patients.