Intervention Tactics Enhance Outpatient Cancer Care, Reduce ED Visits

Key interventions included same-day infusion appointments, multidisciplinary care coordination, and a nurse-led call line.

A 10-pronged intervention strategy including education, a nurse-led call center, and same-day infusion appointments, reduced hospital admissions and emergency department (ED) visits by 16% following chemotherapy treatment, according to a presentation from the 50th Annual ONS Congress.

“We’ve connected with, actually, over 5000 of our patients [at high-risk for chemotherapy-related symptoms] through the call center,” Joy Joseph, MSN, RN, OCN, director of outcome and value at AdventHealth Cancer Institute, said during her presentation at the meeting.

CMS OP-35 Measure

The Centers for Medicare & Medicaid Services (CMS) measure OP-35 is a core measure of the admissions and ED visits for 10 potentially preventable conditions (anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis) within 30 days of receiving outpatient chemotherapy.

This measure is only evaluated among hospital-based infusion centers and excludes practice-based infusion centers. For patients to be included in this core measure, they must be adults aged 18 years or older and be a Medicare FFS patients with a diagnosis of cancer at the start of the performance period.

Patients excluded from OP-35 are those with a diagnosis of leukemia at any time, patients who do not have at least 1 outpatient chemotherapy treatment followed by continuous enrollment in Medicare FFS Parts A and B in the 30 days after, and those who were not enrolled in Medicare FFS Parts A and B in the year before their first outpatient chemotherapy treatment during the performance period.

“That’s a large population. When you look at the cancer patients, just because [of age of diagnosis], our patients do become Medicare eligible much younger than 65 years old,” explained Joseph.

In 2022, AdventHealth fell below the CMS national average (4.4% vs 5.4%, respectively) of ED visits for patients receiving outpatients chemotherapy; however, the average exceeded the CMS national average for inpatient admissions for patients receiving outpatient chemotherapy (13.6% vs 10.4%).

“You can see where we had some opportunity that we needed to improve our patients being admitted after chemotherapy,” said Joseph.

ED Reduction Interventions

In accordance with CMS quality measures that impact the CMS hospital star rating, the team aimed to apply strategies to lower hospital admissions and emergency room visits after outpatient chemotherapy.

The intervention included:

• Plan-Do-Study-Act (PDSA): Initiating the PDSA process to kick off the project with subject matter experts
• Provider/Staff Education: Evaluating baseline understanding and delivering education on the measure methodology
• Patient Education: Creating targeted educational materials focused on the adverse effects specified by CMS
• Improved Care Coordination: Engaging a multidisciplinary care team across multiple departments
• Oncology Nurse Hotline: Establishing a call center for patients to obtain immediate advice and support
• Triage Pathways: Utilizing midlevel providers to reduce ED visits and decrease the burden on provider schedules
• Same-Day Appointments: Utilizing infusion centers for outpatient symptom management
• Home-Based Care: Partnering with a healthcare service for home-based urgent care when patients could not return to the infusion area
• Physician Champions: Leveraging physician leaders to assist in creating awareness
• Monitoring: Creating a reporting structure to track metrics and establishing feedback loops to continuously refine and improve care processes.

Joseph noted that education was a key strategy in this intervention—for both nurses and providers as well as the patients.

“We wanted to make sure that [the providers] understood that it’s not best practice for us to just say, ‘Go to the emergency room.’ [We need to] see what we can do in the outpatient setting,” she added. “[For the patients, it was] making sure they understood that before they go to their emergency room that they need to call us. We can help manage their symptoms in the outpatient setting.”

In addition, because AdventHealth has 8 campuses, 7 infusion centers, and 8 medical oncology practices, Joseph highlighted the vital need for improved care coordination. “It was important that we were making sure we communicated with our navigation team, our pod nurses, our physicians and nurse practitioners in infusion, that they were all on the same page as the care to these patients.”

She also emphasized the creation of the oncology nurse hotline. For the hotline, the team wanted to ensure patients had 1 central place that they could call when they were experiencing symptoms. “So we established a call center…and then we can help treat them on our outpatient infusion areas,” Joseph explained. “We developed triage pathways so that when the patients did call back in, that our [advanced practice providers] in the infusion area would know how we were going to treat it, what medicines we had, or availability, things like that.”

However, the biggest opportunity made with the intervention, according to Joseph, was the same-day infusion appointments. “That’s not always that easy to do, but we made the commitment that if a patient called us, they needed to come back in, that we would see them that same day at any one of our infusion centers to treat them,” she said, adding that they also partnered with a home-based medical practice so that if a patient could not return to the infusion center, the team would send someone to triage the situation at the patient’s home.

Joseph did note a few barriers associated with trying to implement these interventions, such as staffing issues, reporting challenges, and technology constraints.

Reference

Joseph J. Enhancing outpatient care: Strategies to reduce emergency room visits and hospital admissions post chemotherapy. Presented at: 50th Annual ONS Congress; April 9-13, 2025; Denver, CO.