This Article Abstract Full Text (PDF) eLetters: Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article link to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Higman, S. A. Articles by Young, R. C. Search for Related Content PubMed PubMed Citation Articles by Higman, S. A. Articles by Young, R. C.

Fox Chase Network: Fox Chase Cancer Center's Community Hospital Affiliation Program

Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA

Correspondence: Susan A. Higman, B.S., Vice President, Managed Care and Network Development, Fox Chase Network, 8 Huntingdon Pike, Rockledge, Pennsylvania 19046, USA. Telephone: 215-728-4773; Fax: 215-214-1632; e-mail: sa_higman{at}fccc.edu

	ABSTRACT

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
Fox Chase Cancer Center developed a format for affiliation with community providers in 1986. Fox Chase Network was formed to establish hospital-based community cancer centers to increase access to patients involved in clinical research.

Under this program, the Fox Chase Network now contributes 500 patients per year to prevention and clinical research studies. As relationships with community providers form, patient referrals have increased at Fox Chase Cancer Center and for each Fox Chase Network member.

A dedicated staff is required to operate the central office on a day-to-day basis as well as at each affiliate. We have found this to be a critical element in each program's success.

New challenges in the cancer business—increasing volumes with declining revenue—have caused us to reconfigure the services offered to affiliates, while maintaining true to our mission: to reduce the burden of human cancer.

Key Words. Community-based • Clinical research • Cancer network • Affiliation

With hospital systems, payor mergers, and Integrated Delivery Systems all in vogue, the concept of a "Network," even a "Cancer Network," doesn't seem impressive. In 1986, when Fox Chase Cancer Center in Philadelphia incorporated Fox Chase Network to form partnerships with community hospitals, eyebrows were raised. The suspicions occurred in not only oncology circles and the Philadelphia hospital community, but also within the walls of Fox Chase Cancer Center. "Would the Fox Chase image be tarnished?" "You have to own these physicians and facilities!" "How could we assure high quality patient care?" "You're helping the competition!"

Since then, Fox Chase Network, Inc. has built a hospital network of 22 community programs in Pennsylvania and New Jersey, helped to organize and administer the Oncology Physician Network (an independent practice association of medical and radiation oncologists) and acquired a mobile mammography program from a joint venture with a major managed care plan to bridge relations with employers through worksite screening programs. Throughout this period, tumor registry accessions have increased at Fox Chase from 1,485 to 2,464 patients annually. Not only hasn't the "competition" (the affiliated programs within our primary service area) stolen our patient population, both Fox Chase and the community hospitals have increased market share in those regions (Fig. 1).

View larger version (40K): [in this window] [in a new window]   Figure 1. Fox Chase Network Affiliates.

The hospital is licensed for 100 beds, eight of which are in the intensive care unit. A 10-bed unit is devoted to translational research, focusing on phase I trials. Surgery is offered in the hospital and ambulatory settings. Over 6,000 patients visit Fox Chase annually, with more than 4,000 staying for all or part of their treatment. Training programs are offered in medical, clinical and research arenas either directly or in conjunction with other Philadelphia academic centers. Under the Fox Chase umbrella, about 800 patients are placed on clinical research studies each year, with an additional 100 enrolled in prevention programs. About half of those accruals are from the member hospitals of Fox Chase Network.

	FORMATIVE PERIOD

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
Fox Chase Cancer Center formed the hospital network at a time when it was restructuring its clinical research programs. The focus of the clinical research program would increase phase I and II studies; however, the participation in phase III research activities through large national trials would need to be maintained. To advance the goal of increasing Fox Chase's clinical research activity, access to additional or new patient volumes would be required. The option of building more patient beds to increase the overall clinical volume did not seem viable due to the drain it would place on limited capital funds, as well as the already existing over-capacity of hospital beds, particularly tertiary beds, in Philadelphia. In the mid-1980s, Philadelphia had five medical schools, and two NCI-designated comprehensive cancer centers (Fox Chase and University of Pennsylvania Cancer Center). Four teaching hospitals were performing bone marrow transplants and there were two dedicated children's hospitals. Over 82 hospitals were members of the Delaware Valley Hospital Council, which covered southeastern Pennsylvania and southern New Jersey. Managed care represented less than 10% of the insured market. Today, there are four medical schools, four major health delivery systems, and over 62% of the market is covered by managed care programs, including 38% of Medicare-eligibles and nearly 100% of Medicaid beneficiaries.

In this competitive environment, Fox Chase needed to develop multiple approaches to increase its access to patients to fulfill the research mission. First, Fox Chase decided to focus its efforts on adult solid tumors. The market was saturated with pediatric and nonsolid cancer programs; it did not make sense to build new ones. Next, we began advertising, the only health care facility in Philadelphia to do so at the time. By creating a brand recognition for cancer care, all of our target market—patients, physicians, and payors—would be drawn to Fox Chase. Television, particularly cable, combined with print and radio, has proven to be the most successful medium.

A method to support our shift to early phase clinical research would be to move the bulk of the phase III activity to community oncologists. Fifteen years ago, Fox Chase had little experience working with community providers. Like many tertiary centers, we were accused of "stealing" patients. The medical practice of Fox Chase through the early 1980s was independent of the hospital. One of the oncologists, Paul Engstrom, M.D., devoted one day a week to circuit-riding to community hospital locations. Given this exposure to area hospitals and his interest in cancer control initiatives, he realized the potential to work with community practitioners. The first attempt at collaboration was the clinical research affiliation offered to community hospitals through Fox Chase's participation in the Eastern Oncology Cooperative Group. A few hospital programs outside the Philadelphia region were affiliated with us for that purpose. This limited research affiliation was a first step in partnering with community providers, but was not the model envisioned for this new patient access and management system.

We held conversations with executives at health plans and local hospitals to formulate our visions of an infrastructure to support a patient-access model. Fox Chase Network was organized in 1986 with dedicated administrative and clinical staff from Fox Chase Cancer Center supplemented with a medical director, marketing director and support staff experienced in community practice. The team focused on the essential elements to link a community hospital to an academic center to assure high-quality patient care and appropriate utilization of resources.

Through extensive market research, four locations were identified for program development. The chief executive officers (CEOs) at those hospitals agreed to presentations to the hospital boards of trustees and medical staffs. The community partners were interested in developing oncology services due to the increasing incidences of cancer caused by the aging of the population, as well as the perceived need for a marketing edge over their local competition. Fox Chase offered to build joint radiation therapy facilities/programs, consult over the design of "cancer center" facilities, oversee the training, and assist with staffing at the hospitals.

	PROGRAM OPERATIONS

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
Today, each program is assessed from a clinical, research, business and marketing perspective with a corresponding individualized implementation plan. Prior to conducting the assessment or beginning program development, a letter of intent is executed by the hospital and Fox Chase. This outlines the structure of the affiliation and obligation of the hospital, its physicians and Fox Chase Cancer Center or Fox Chase Network. The assessment usually begins while the formal agreement is being developed.

The Clinical Plan consists of an overview of all services available that touch the cancer patient, with recommendations for improvements to meet industry or Fox Chase standards. Fox Chase remains diligent in its standards for program affiliation and the core components required of a partner. In some hospitals, the patient volume, treatment programs and support services necessary to expand oncology are not in place and a business plan focuses on the administration, financing and implementation of the component(s). Often the hospital needs facility development and/or redesign to create an inpatient cancer unit, outpatient chemotherapy administration suite, and radiation therapy center, or consolidation of support services—social work, nutrition, tumor registry. The development of a cancer center facility to centrally house most of these services often results in successful program roll-out and implementation (Fig. 2).

View larger version (31K): [in this window] [in a new window]   Figure 2. Hospital program components.

Since the formation of Fox Chase Network, efforts have focused on assuring quality patient care and enrollment into appropriate clinical trials. In the early days, work-up, staging and treatment processes at the community locations were standardized via The Patient Management System^TM, a PC-based information system developed by Fox Chase and accessed via modem by each hospital. Every patient encounter was logged onto the system after consulting the appropriate modules for decision-making. In 1986 the concept was visionary, but now is being implemented by many disease management and case management programs to aid health professionals in developing standards for work-ups, staging and treatment, and to measure concordance or deviation from the standards. A barrier to the consistent utilization of these tools is the extra human resources needed to access yet another information system. To be successful, implementation of such tools should replace current processes and become part of daily operations.

In 1994 our efforts in patient data management refocused to primarily support research activities, since most hospital information systems, including tumor registries, capture relevant patient treatment information. Today the network hospitals relate to Fox Chase through a web-based protocol management system which tracks the patient data for clinical studies, as well as the specific reporting requirements including IRB processes. The system catalogs Fox Chase protocols available to the affiliate hospitals as well as open cooperative group studies. The system may be customized to include research studies active at the network hospitals and not conducted through Fox Chase. The Internet provides an excellent resource for ongoing communication and program interaction through the web-based system as well as e-mail. Other electronic communication systems, such as video teleconferencing, enable more frequent dialogue than travel schedules allow. With the increasing geographic extension of the network, new communication tools are needed to maintain the standard of support provided to our network members.

Fox Chase participates in a number of quality assurance programs at the network hospitals. Radiation therapy treatment is monitored by Fox Chase Cancer Center radiation oncologists and physicians through regular on-site visits and chart reviews. New programs are assessed monthly with a shift to quarterly visits after programs are well established and operating smoothly. Fox Chase Network, Inc. staff also participate in cancer and quality assurance committees at the member hospitals, bringing relevant resources from Fox Chase to the local programs.

Because the success of the clinical program is directly related to awareness of the available clinical, medical and support services, Fox Chase Network, Inc. supports its hospital programs' marketing efforts in two ways. A marketing plan is developed for each partner focusing on the capability of the program and available services to important audiences. The plan begins with market research that assesses environmental factors such as access, competition, demographics of the community (age, gender, income, and education) and any potential cultural barriers. Patient and physician referral patterns are analyzed to determine referral trends and barriers to overcome. The plan outlines the advertising, promotion and awareness strategies to be implemented over a 12- to 24-month period, and includes design and creation of the materials. The budget is jointly developed by the staff at Fox Chase Network and the community program, with advertising placement and production costs paid by the hospital. Each program assigns someone to serve as marketing liaison for the cancer program, thus assuring that the specific cancer product line is not lost in the overall marketing strategy of a community hospital. Fox Chase Network, Inc. also promotes the entire hospital network in regional media to showcase the scope and capability of its members. In some cases, the hospitals and physicians become referral sources for one another if specialized services are available only at select locations.

	CRITICAL SUCCESS FACTORS

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
Each program's success is dependent on the ability to attract new patients and retain existing referral patterns to the community hospital. Supportive medical staff at the hospitals has become one of the "critical success factors." Without a strong advocate of the affiliation from within the medical staff, the new cancer program may not be successful. For this reason, a program medical director is selected from the hospital medical staff. It has usually been a medical oncologist. A formal medical director agreement is executed among the three parties—Fox Chase Cancer Center, the community hospital and the medical director. A stipend is paid by the hospital and Fox Chase monthly to support the administrative services conducted by the medical director on behalf of the cancer program. In some cases, the stipend is incentive-based with obligations to meet certain annual goals, including clinical trial accrual (Fig. 3).

View larger version (29K): [in this window] [in a new window]   Figure 3. Critical success factors.

By linking the physicians, a dedicated program administrator and a well-trained clinical staff to a central facility and planning document (the clinical plan almost serves as a strategic plan for the cancer program), our network hospital affiliates have increased their patient volume by one-third to twofold. Tumor registry volumes at the hospitals have grown steadily, especially the nonanalytic or reference cases, indicating that the Fox Chase Network hospitals are recognized as regional referral centers in their community.

During the early years of Fox Chase Network, we recognized that each community hospital has its unique structure, culture and issues. We realized that to be successful, the programs would need to reflect the community and be tailored accordingly; a "cookie cutter" approach would not work. Each hospital's cancer program's goals, priorities, and services are developed specifically; however, the core components of a Fox Chase Network-affiliated program remain the same. We also learned that the decision-makers in the community are not necessarily the obvious hierarchy of CEO or chief medical officer. Often the most important determinant of successful program implementation and development is the cooperation of a practicing physician who has a loyal following but may not be a department chairman.

	STRUCTURE AND SERVICE

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
Fox Chase Network operates differently today than at its creation in response to the challenges of today's health care delivery systems. Seventeen people contribute to the operations of the network. This includes dedicated administrative, marketing, clinical and research staff supporting the programs on a day-to-day basis. Occasionally, staff with specific expertise are brought in to support special projects or specific needs of the hospitals (managed care contracting, case management, etc.). The medical leadership of Fox Chase Network, Inc. consists of practicing Fox Chase Cancer Center oncologists who spend part of their time with the community hospitals in quality or administrative oversight roles. Dr. Paul Engstrom has served as medical director since 1990. He shares his expertise in community practice, cancer control, and population sciences including genetics, high-risk program development and behavioral research. Dr. Mark Cornfeld was recently recruited to serve as associate medical director for Fox Chase Network along with the appointment as medical director of our corporate outreach program. Dr. Cornfeld brings community practice experience to our team with an emphasis on public health and high-risk assessment.

Network partners face increasing pressure to reduce program expenses while reviews by regulatory or accreditation bodies increase. The clinical interaction between Fox Chase Cancer Center and the Fox Chase Network member occurs at three levels: first, the program-planning document (formerly clinical plan) is updated every two to three years. The review process operates out of the partner hospital's cancer committee thus consolidating program planning and development. Second, the plan focuses on the accreditation standards of the Joint Commission on Accreditation of Healthcare Organization (JCAHO), American College of Surgeons (ACoS), American College of Radiology (ACR), etc. As the requirements for accreditation change, the cancer committee, through the program plan, focuses on meeting or exceeding the standards. Third, introduction of new services, products or programs at each hospital is done only after careful consideration of revenue opportunities with expenses covered through operating revenues, grants, or other awards. Where possible, programs learn from one another or services/programs are packaged into modules by Fox Chase Network staff for easier implementation at the partner hospitals. Training symposiums are often held to facilitate new program introduction.

Fox Chase encourages accreditation by the ACoS Commission on Cancer for each of our network hospitals because the ACoS core components strengthen cancer programs. New partners in our network are encouraged to build the program using the standards of ACoS and to seek its review and accreditation as quickly as possible. The cancer committee serves a critical function in both the College's and our view to achieve a consolidated and collaborative cancer product line. Regular tumor boards and accrual to clinical research based on the number of patients accessioned to the tumor registry are critical elements that insure that patients are offered multidisciplinary, state-of-the-art cancer care.

In some cases, hospitals interested in joining the Network have well-established cancer programs but desire access to further research, education, or simply brand recognition. Each of these programs is reviewed individually to assure that core components are established, the geographic location and service area do not violate the restrictive covenants in other affiliation agreements, and to determine that the hospital will provide a benefit to Fox Chase Cancer Center or other members of Fox Chase Network. Some of these hospitals were better suited to alternative affiliation structures. As long as the Fox Chase Network program selection criteria are met, we are open to alternate affiliation models (Fig. 4).

View larger version (27K): [in this window] [in a new window]   Figure 4. Selection criteria.

View larger version (29K): [in this window] [in a new window]   Figure 5. Fox Chase Network operations.

We attribute the longevity and success of the network to the staff and members' ability to respond to change. As cancer care has moved into physicians' offices, Fox Chase developed direct working relationships with oncologists. The hospitals then focused on specialized and/or supportive services to offer patients. Some services were integrated among the physicians, hospital and other community providers. Multidisciplinary programs have developed at many of the hospitals, bringing specialists together to evaluate patients. Direct mail cancer education programs in colorectal and breast cancer brought oncologists, surgeons, and internists together to outline early detection methods and treatment options.

	FUTURE PLANS

Top Abstract Formative Period Program Operations Critical Success Factors Structure and Service Future Plans

 
As we enter the new millennium, Fox Chase Network will continue to evolve. Members of Fox Chase Network are interested in demonstrating the quality of their practice and institution through several new initiatives. Medical oncology quality assurance measures have been implemented during the last year in some of the practices located at Fox Chase Network member hospitals. Chart reviews have begun to analyze treatment decisions, opportunity for participation in clinical trials, and complication rates. The response of the medical oncologists has been favorable. Fox Chase Network has also developed a Quality Improvement/Performance Improvement Committee to address pain management and end-of-life issues. Both topics are key JCAHO and ACoS issues that are of significant importance. All Network hospitals actively participate in this program.

Another opportunity for outcome comparisons lies with Fox Chase Cancer Center's membership in the National Comprehensive Cancer Network (NCCN). As the NCCN continues to develop outcome data, community practice data will need to be added to make the database more representative. Fox Chase Network, Inc. and NCCN are reviewing the methods for community data collection and submission to the breast cancer outcome project.

Some new models for affiliation are likely to emerge. Recent requests from current members indicate an interest in bringing highly specialized surgeons to the community hospitals, as well as demonstrated oncology leaders to build multihospital integrated cancer programs. Fox Chase Network may serve as a physician recruitment and practice management arm if these services are reasonable and within our mission (Fig. 6).

View larger version (26K): [in this window] [in a new window]   Figure 6. Fox Chase Network models.

The Research Institute for Cancer Prevention was completed in March 2000 and will expand our scientific understanding of cancer and enhance our ability to use this information to prevent cancer. Fox Chase Cancer Center's strong programs in critical disciplines have already contributed substantially to the development of cancer prevention research, and we are now poised to expand our base of expertise to realize the full potential of this field.

One of our cancer prevention initiatives is the Fox Chase Family Risk Assessment Program, which studies genetic predisposition to cancer in families. Programs in breast, ovarian and prostate risk assessment are being exported to Network hospitals for education and recruitment of subjects from the community. Many community practitioners have greater access to families than a tertiary facility like Fox Chase; therefore, cancer clusters are more easily identified. Access to those high-risk programs in the community, near their physicians, friends, and homes, enables more high-risk families to understand and possibly change their risk of developing cancer.

Early detection and prevention efforts are some of the best means to help control health care costs in our nation. Health plans may rely on new methods to manage specific diseases. Fox Chase and its network of hospitals are poised to launch a disease management initiative focusing on high-quality, cost-effective cancer care closer to home. Offering excellent preventive services along with state-of-the-art treatment could position the Fox Chase-related providers as referral centers.

One of Fox Chase's other new initiatives is a corporate outreach program. Can Prevent/A Partnership at Work^TM offers cancer awareness, screening and prevention programs at the work site. Partnering with employers and other payers of health care may provide the right incentives and structure for disease management initiatives.

The changing demographics in our country, reductions in payments for highly technical cancer therapy and the emerging cancer prevention programs will provide many opportunities for Fox Chase Cancer Center in the future. Our Fox Chase Network partners have become the leaders in their community and facilitators of the knowledge gained in Fox Chase Cancer Center laboratories and clinics. The development of Fox Chase Network has been an essential element in Fox Chase Cancer Center's ability to respond to the changing market and remain committed to our mission.

Received June 13, 2000; accepted for publication July 3, 2000.

This Article Abstract Full Text (PDF) eLetters: Submit a response to this article Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article link to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Reprints/Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Higman, S. A. Articles by Young, R. C. Search for Related Content PubMed PubMed Citation Articles by Higman, S. A. Articles by Young, R. C.