Participants are responsible for meeting a variety of requirements related to care coordination, patient-centered care, technology, patient safety, and clinical and quality data reporting each performance year (PY). Failure to meet these requirements will jeopardize participants’ ability to receive an APM Incentive Payment.

Requirement one

Discuss goals of care with each RO beneficiary before initiating treatment and communicate to the RO beneficiary whether the treatment intent is curative or palliative (applies to professional and dual participants only)

Best practice implementation steps

1. Assign responsibility for having goals of care discussions with patients, and provide necessary training
2. Consider investing in or developing shared decision-making tools to help patients prepare for goals of care discussion
3. Standardize timing of goals of care discussion; build it into clinical workflow
4. Designate responsibility for documenting completion of goals of care discussion; standardize documentation format
5. Hardwire check point before treatment start for each patient to confirm goals of care discussion has happened to avoid missing performance targets

Supporting resources

• Case study excerpt: Facilitate Shared Decision Making
• Case study excerpt: Leverage technology to hardwire discussion about treatment goals

Requirement two

Adhere to nationally recognized, evidence-based clinical treatment guidelines when appropriate in treating RO beneficiaries or, alternatively, document in the medical record the extent of and rationale for any departure from these guidelines (applies to professional and dual participants only)

Best practice implementation steps

1. Select evidence-based guidelines or clinical pathways to use
2. Determine how to monitor and document guideline concordance (e.g., multidisciplinary treatment planning conferences, clinical pathways or other clinical decision support tool, manual chart reviews)
3. Generate weekly/monthly reports on physician-level guideline concordance and include peer benchmarks
4. Examine instances of non-concordance and identify improvement opportunities

Supporting resources

• Resource: Three steps to become evidence-centered
• Case study excerpt: See how Northwell identified opportunities to improve safety
• Blog: The latest trends on clinical pathways in oncology

Requirement three

Assess each RO beneficiary’s tumor, node, and metastasis cancer stage for the CMS-specified cancer diagnoses (applies to professional and dual participants only)

Best practice implementation steps

1. Assign responsibility for performing assessment
2. Standardize timing of assessment; build it into clinical workflow
3. Designate responsibility for documenting assessment findings; standardize documentation format

Requirement four

Assess the RO beneficiary’s performance status as a quantitative measure determined by the physician (applies to professional and dual participants only)

Best practice implementation steps

1. Standardize performance status scale used
2. Determine appropriate frequency of performance status assessment; build it into clinical workflow
3. Designate responsibility for documenting performance status; standardize documentation format

Supporting resources

• Case study excerpt: Create a comprehensive palliative care plan

Requirement five

Send a treatment summary to each RO beneficiary’s referring physician within 3 months of the end of treatment to coordinate care (applies to professional and dual participants only)

Best practice implementation steps

1. Select or develop treatment summary template
2. Identify data sources required to complete summary and assign responsibility for populating template
3. Set up trigger for when treatment has ended and treatment summary should be created and sent
4. Select method and assign responsibility for sending summary to referring provider and delivering summary to patient

Supporting resources

• Case study excerpt: Automate sharing of patients’ treatment and survivorship plans with their PCPs
• Webinar slides: Streamline treatment summary and care plan creation

Requirement six

Discuss with each RO beneficiary prior to treatment delivery his or her inclusion in, and cost-sharing responsibilities under, the RO Model (applies to all participants)

Best practice implementation steps

1. Personalize beneficiary Model inclusion notification template provided by CMS
2. Determine most feasible method to develop out-of-pocket (OOP) cost estimates (manual, homegrown tool, automated tool)
3. Assign responsibility for discussing RO Model inclusion and financial responsibility with patients; build it into clinical workflow at beginning of treatment
4. Train designated staff to effectively and sensitively discuss financial responsibility with patients

Supporting resources

• Resource: Help patients understand their financial responsibility
• Research study excerpt: Financial conversations scripting
• Research study excerpt: Understanding your health benefits
• Research study excerpt: Standardize new patient appointments
• Research study excerpt: Educate Patients About Their Financial Responsibility

Requirement seven

Perform and document peer review (audit and feedback on treatment plans) before 25% of the total prescribed dose has been delivered and within 2 weeks of the start of treatment for 50% of all radiation therapy patients in PY1, to increase by 5% each PY (applies to professional and dual participants only)

Best practice implementation steps

1. Develop criteria to determine which patients should receive peer review
2. Standardize timing of peer review
3. Assign responsibility for documenting peer review; standardize documentation format
4. Track percentage of new patients receiving peer reviewed treatment plans in real time to avoid missing annual targets

Supporting resources

• Case study excerpt: See how Northwell identified opportunities to improve safety

Requirement eight

Attest annually to active participation in a radiation oncology-specific AHRQ-listed patient safety organization (PSO) (applies to technical and dual participants only)

Best practice implementation steps

1. Find out if you actively participate in a PSO that meets Model requirements
2. If not:
   • Evaluate radiation oncology-specific AHRQ-listed PSO options
   • Select PSO to enter into a contractual or similar relationship for the receipt and review of patient safety work product
3. Attest participation in PSO to CMS by stipulated annual deadline

Supporting resources

• Resource: Radiation oncology-incident learning system (RO-ILS)

Requirement nine

Use of certified EHR technology (CEHRT) (applies to all participants)

Best practice implementation steps

1. Ensure that your individual practitioners use CEHRT
2. Certify to CMS annually that you plan to use CEHRT during the upcoming performance year (PY) 30 days prior to start of PY
3. Verify and certify annually the individual practitioner list provided by CMS at the start of the PY within 30 days of receipt

Supporting resources

• Expert insight: An IT update: Trends and challenges of EHRs in oncology
• Tool: Oncology EHR optimization crosswalk 

Requirement ten

Meet applicable quality, clinical data, and patient experience measure reporting and performance requirements (applies to all participants, applicable requirements vary by participant type)

Best practice implementation steps

1. Identify data elements required to calculate performance measures
   • Where data element is stored in patient record
   • Whether data is structured or free text
   • Consistency of documentation (completeness, format, units of measure)
2. If data element is not already documented, determine:
   • Documentation process, who is responsible, and accountability mechanism
3. Assess feasibility of automated reporting on performance measures and/or assign responsibility for manual reporting

Supporting resources

• Research study: Measuring oncology service line performance
• Research study excerpt: Prospective process to identify opportunities for quality improvement
• Toolkit: The oncology dashboard toolkit

Participants are evaluated on a mix of pay-for-reporting and pay-for-performance quality, clinical data, and patient experience measures. These measures determine quality reconciliation payments.

For dual and professional participants, an aggregate quality score (AQS) will be calculated based on quality measure reporting and performance and clinical data reporting starting in PY1. Starting in PY3, patient experience scores will be factored into the AQS for dual and professional participants; technical participants will begin seeing a patient experience withhold that they will have the opportunity to earn back based on their patient experience scores.

Quality measure one

Plan of care for pain (applies to professional and dual participants only; pay-for-performance for PY1-5)

Best practice implementation steps

1. Assign responsibility for conducting pain assessment and documenting plan of care
2. Standardize pain assessment tool and timing of pain assessment; build assessment into clinical workflow
3. Develop clear criteria for which pain assessment results warrant a plan of care for pain; standardize key elements to include in care plan
4. Create mechanism to ascertain and incorporate patient wishes into plan of care

Supporting resources

• Research study excerpt: Leverage patient care planning platform to improve pain assessment and care plan documentation
• Case study excerpt: Create a comprehensive palliative care plan
• Resource: Distress screening playbook

Quality measure two

Screening for depression and follow-up plan (applies to professional and dual participants only; pay-for-performance for PY1-5)

Best practice implementation steps

1. Select age-appropriate standardized depression screening tool to use
2. Assign responsibility for conducting depressing screening
3. Standardize timing of depression screening; build it into clinical workflow
4. Assign responsibility for documenting follow-up plan for positive depression screens; standardize elements included in follow-up plan

Supporting resources

• Resource: Distress screening playbook

Quality measure three

Advance care plan (applies to professional and dual participants only; pay-for-performance for PY1-5)

Best practice implementation steps

1. Assign responsibility for discussing advance care plan with patient and provide necessary training
2. Consider investing in or developing educational resources to help patients prepare for advance care plan discussion
3. Standardize timing of advance care plan discussion; build it into clinical workflow
4. Assign responsibility for documenting advance care plan; standardize documentation format

Supporting resources

• Resource: Advanced care planning routine for all cancer patients
• Research study: Overview of common types of advance care planning documents 
• Research study excerpt: How to make advance care planning a critical component 

Quality measure four

Treatment summary communication (applies to professional and dual participants only; pay-for-reporting for PY1-2, pay-for-performance for PY3-5)

Best practice implementation steps

1. Select or develop treatment summary template
2. Identify data sources required to complete summary and assign responsibility for populating template
3. Set up trigger for when treatment has ended and treatment summary should be created and sent
4. Select method and assign responsibility for sending summary to referring provider and delivering summary to patient

Supporting resources

• Research study excerpt: Automate sharing of patients’ treatment and survivorship plans with their PCPs
• Webinar slides: Streamline treatment summary and care plan creation

Quality measure five

CAHPS Cancer Care Radiation Survey for Radiation Therapy (applies to all participants; pay-for-performance for PY3-5)

Best practice implementation steps

Survey will be administered to patients by CMS, but to ensure high performance:

1. Review survey questions in advance
2. Identify opportunities for improvement proactively based on historical patient and staff feedback
3. Implement initiatives to target identified opportunities for improvement
4. Adjust improvement initiatives' focus as needed as RO Model patient experience data becomes available

Supporting resources

• Research brief: What matters most to cancer patients
• Tool: Cancer patient experience survey results portal
• Infographic: Charting the cancer patient journey
• Event recording: What matters most to cancer patients

Quality measure six

Clinical data elements (applies to professional and dual participants only; pay-for-reporting for PY1-5)

Best practice implementation steps

1. Identify data elements required for reporting
   • Where data element is stored in patient record
   • Whether data is structured or free text
   • Consistency of documentation (completeness, format, units of measure)
2. If data element is not already documented, determine:
   • Documentation process, who is responsible, accountability mechanism
3. Assess feasibility of automated reporting on data element and/or assign responsibility for manual reporting

Supporting resources

• Research study: Strategic road map for cancer quality