Oncology Medical Home

An Oncology Medical Home is a care delivery system that is physician-led, directing a team to provide patient and family support through the patient care journey of diagnosis, treatment, and follow-up care. This physician-led team is primarily responsible for care coordination that enhances patient care experiences, clinical outcomes, and quality of life.

What is Care Coordination?

Communication within the practice team and other physicians and services caring for you include primary care physician, specialty providers, outside agencies like home care, rehabilitation, support services, and community resources.

Education about your diagnosis, treatment, follow-up, and support services.

Symptom triage support for easy access to the practice and providers to address your health concerns quickly to avoid emergency department visits or unplanned hospitalizations.

Support through the patient care journey including initial diagnosis, treatment plan, symptom management, survivorship, and supportive care.

Call us first for any concerns or health issues related to your care.

What can you expect?

Information on how and when to contact the medical oncologist, including evenings and weekends, with issues that need to be addressed. A contact phone number, a 24/7 or alternative direct line for your care team will be provided at your first visit. This number is for after-hours service and care (e.g., holidays and weekends). Patients’ care team names (e.g., medical oncologist, APP, navigator, care coordinator, social worker).

What to call for?

Urgent symptoms

Routine symptoms

Where to go for care?

Oncologist

• Care related to diagnosis and treatment
• Symptoms related to diagnosis and treatment (e.g., fever, nausea/vomiting, diarrhea, pain control)
• Medication refills prescribed by your medical oncologist

Primary Care Physician

• Annual wellness visits
• Managing chronic disease, such as diabetes and high blood pressure including medication refills
• Ear, sinus, or urinary tract infection

Emergency department

• Chest pain or difficulty breathing
• Broken bones or dislocated joints
• Fainting, change in mental status, or slurred speech
• Head or eye injuries
• Weakness and/or numbness in one side
• Uncontrolled bleeding

Responsibilities of the patient and of the practice.

Patient Responsibilities

• Provide your medical history and current medical information for effective care
• Provide information for your primary care physician and other specialty care team members to assure communication and care coordination
• Participation in healthcare decision-making
• Communicate to your care team early and often with any health issues or care concerns
• Provide health benefits information and updates
• Notification of need to reschedule or cancel an appointment

Practice Responsibilities

• Patient care with respect and recognized as an individual with needs and preferences
• Information to support patient healthcare decision-making
• Estimated out-of-pocket expense for any new therapy that is offered with financial counseling service
• Equitable and comprehensive team-based care
• 24/7 availability to a provider for care needs
• Provide missed appointment policy and expectations for rescheduling and cancelling appointments
• Deliver high quality, safe, and effective care