Why In-Person, Embedded Care?
“Wait, you’re telling me that Atlas care team members will be onsite and in-person at my practice?”
While integrating embedded care models into practice workflows requires coordination and planning, Atlas fundamentally believes that supportive care services are an integral part of high-quality cancer care and must be deployed in close collaboration with the primary oncologist. Digital-forward methods, like app-based symptom tracking, allow for coverage across a broad area and home-based supportive care meets the patient in a comfortable, familiar setting. These approaches have their place, and while we frequently leverage telephonic, digital, and telemedicine solutions, we built Atlas to support the oncologist-patient relationship though an embedded partnership.
The oncology practice becomes the quarterback
Once an individual is diagnosed with cancer, the oncology practice transforms into the hub. The complexity of cancer care is accelerating rapidly while the oncology team is assuming increasing ownership for more just the direct cancer care. Primary care clinicians, specialists, hospital providers, home health agencies, family members, and patients all look to the oncology team as the quarterback of care, even if the issue is “cancer-adjacent”. For example, patients often start turning to their oncologist first for management of their chronic medical issues (diabetes, heart failure), support for psychosocial challenges (transportation and financial support), coordination of ancillary care (physical and occupational therapy, nutrition services), symptom management, and other unplanned care needs that occur at all hours of the day and night. While individual oncologists and oncology practices are doing everything they can to meet these needs, there is never enough capacity, time, or resources – and there certainly is no sustainable reimbursement model. Atlas brings additional resources and capabilities into the oncology practice but focused specifically on identifying and relieving these cancer-adjacent issues.
The evidence supporting our approach
The Atlas care model builds on research led by Atlas’s own Chief Medical Officer, Dr. Gabrielle Rocque. Dr. Rocque and her team embedded lay navigators into 11 community oncology centers and one academic center in the Gulf South as part of a large, multi-year pragmatic study funded by the Center for Medicare and Medicaid Innovation.
The embedded lay navigation program reached 6,214 Medicare patients with cancer. Cost and utilization of the navigated patients was measured against that of a comparable population of non-navigated patients. The results, which were published in JAMA Oncology, demonstrated an 8% greater reduction in total Medicare costs of care savings in the navigated group compared to the control population, driven mainly by reductions in inpatient and outpatient costs. Emergency department visits declined 6.0%, hospitalizations declined 7.9%, and ICU admissions declined 10.6% more per quarter.¹ Multiple subsequent randomized controlled trials on similar interventions demonstrate total cost of care savings in the 23-34% range across a variety of clinical settings.²⁻⁴
Atlas’s approach builds on this evidence base and enhances the clinical model - a larger, multi-disciplinary care team including licensed providers, entirely focused on cancer-adjacent medical and psychosocial issues, supported by sophisticated population-health data and analytics capabilities, and financed by outcomes-based payment models.
The Atlas care team in action
At its core, the onsite, in-person Atlas care team includes APPs, Nurses, LCSWs, Care Coordinators, and Clinical Operations team members. A primary care licensed Medical Director oversees the team either remotely or in person and sees complex patients. Around these services, Atlas also wraps in psychiatrists and pharmacists virtually.
The size and scope of this care team is curated to meet individual practice’s needs to avoid duplicative programs or workflows. For instance, one practice may have an extensive navigation program but needs help building services to support managing comorbid conditions, where another practice may need expansion of navigation to identify and address barriers to accessing care.
The Atlas care team focuses on proactively identifying, diagnosing, documenting, and managing cancer-adjacent issues and has subject matter expertise in how these issues are related (or not) to their cancer diagnosis and treatment. Being truly embedded into the oncology practices, the Atlas care team serves as a trusted, seamless extension of the oncology care team, not a 3rd party vendor. Atlas team members collaborate daily with oncology practice staff and the oncology providers themselves to ensure patients receive the best possible outcome and experience. The Atlas team works in a closed loop with your practice, external PCPs, and specialists, so what happens between visits doesn’t get lost. The Atlas care team does not change the cancer treatment plan or prescribe anti-cancer therapy, and it is not a substitute for the patient’s PCP. The result is a more connected care team dedicated to meeting the complex needs of patients with cancer from within the oncology practice itself.
The case for embedded care
Today, it isn’t a question of whether oncology practices need more support. It’s a question of how that support shows up: as a call from an unfamiliar phone number and unknown person, or as a trusted, coordinated extension of the oncology care team.
If you’re leading a cancer service line or an independent oncology practice and want to talk through what an embedded care team could look like for your patient population, we’d welcome the conversation.
References:
Rocque GB, Pisu M, Jackson BE, et al. Resource Use and Medicare Costs During Lay Navigation for Geriatric Patients With Cancer. JAMA Oncol. 2017;3(6):817–825.
Patel MI, Sundaram V, Desai M, et al. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA Oncol. 2018 Oct 1;4(10):1359-1366.
Patel MI, Agrawal M, Blayney DW. Long-Term Engagement of Patients With Advanced Cancer: Results From the EPAC Randomized Clinical Trial. JAMA Oncol. 2024 Jul 1;10(7):905-911.
Patel MI, Voskanyan M, Agajanian H, et al. A Lay Health Worker–Led Symptom Intervention and Acute Care Use in Older Adults With Cancer: A Randomized Clinical Trial. JAMA. 2026;335(8):674–681.
Patel MI, Ramirez D, Agajanian, et al. Lay Health Worker-Led Cancer Symptom Screening Intervention and the Effect on Patient-Reported Satisfaction, Health Status, Health Care Use, and Total Costs: Results From a Tri-Part Collaboration. JCO Oncol Pract. 2020 Jan;16(1):e19-e28.