BackgroundImplementation science is defined as the scientific study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners. Failure of implementation is more common in resource-limited settings and may contribute to health disparities between rural and urban communities. In this pre-implementation study, we aimed to (1) evaluate barriers and facilitators for implementation of guideline-concordant healthcare services for cancer patients in rural communities in Upstate New York and (2) identify key strategies for successful implementation of cancer services and supportive programs in resource-poor settings.MethodsThe mixed methods study was guided by the Consolidated Framework for Implementation Research (CFIR). Using engagement approaches from Community-Based Participatory Research, we collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship services (three focus groups, n = 43, survey n = 120). Information was collected using both in-person and web-based approaches and assessed attitude and preferences for various models of cancer care organization and delivery in rural communities. Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Data was analyzed using grounded theory.ResultsResponders reported preferences for cross-region team-based cancer care delivery and emphasized the importance of connecting local providers with cancer care networks and multidisciplinary teams at large urban cancer centers. The main reported barriers to rural cancer program implementation included regional variation in infrastructure and services delivery practices, inadequate number of providers/specialists, lack of integration among oncology, primary care and supportive services within the regions, and misalignment between clinical guideline recommendations and current reimbursement policies.ConclusionsOur findings revealed a unique combination of community, socio-economic, financial, and workforce barriers to implementation of guideline-concordant healthcare services for cancer patients in rural communities. One strategy to overcome these barriers is to improve provider cross-region collaboration and care coordination by means of teamwork and facilitation. Augmenting implementation framework with provider team-building strategies across and within regions could improve rural provider confidence and performance, minimize chances of implementation failure, and improve continuity of care for cancer patients living in rural areas.
74 Background: Nearly 3 million cancer survivors in the US reside in rural areas. Existing survivorship care models were developed mainly at large academic centers, and thus require adaption to meet the challenging needs of the rural community. Rural cancer survivors (RCS) face issues with coordination of care, decision-making, access to specialty services, supportive care resources, and time and resources required for travel. RCS are at greater risk for social isolation and inadequate emotional support. To address these challenges, many studies propose information technology (IT), mobile, and video solutions. We assessed the potential of online and mobile video technology applications to reduce barriers to survivorship care for RCS, families, and caregivers. Methods: We conducted 2 in-person focus groups with rural care managers, providers, and public health professionals, and one virtual cross-disciplinary focus group of patients, caregivers, and provider stakeholders to evaluate acceptability of video modules. Using a Community-Based Participatory Research approach, we worked with community partners to design and develop materials that adequately addressed their needs. Results: Focus group results indicate that video modules added little value for RCS due to sporadic internet access, limited patient IT literacy, vision and memory problems, and patient difficulty interpreting information. Therefore, we designed and piloted a paper RCS Checklist to be taken to appointments, available in waiting areas or through care managers, and to serve as a guide for shared patient-provider decision-making. The resulting checklist includes evidence-based information about survivorship care goals and approaches, care coordination strategies, information about local cancer supportive services, health insurance reimbursement, state disability policies, psychosocial support, and stress-reduction tips. Conclusions: In some special patient populations like RCS, use of health IT for patient empowerment and care coordination may be a poor choice. Engaging relevant stakeholders in the development of location-specific communication and decision aid materials is paramount to successful engagement of patients and caregivers.
59 Background: A major challenge in providing quality survivorship care to cancer patients is efficiently and effectively identifying and scheduling patients who need a Survivorship Visit (SV). While the Commission on Cancer (CoC) Standard 3.3 defines which patients require a Survivorship Care Plan (SCP), staff need to operationalize the definition and search the clinic’s patient records on a regular basis to accurately identify eligible patients. This is a challenge for a busy cancer center. Methods: In July 2017 the Judy DiMarzo Cancer Survivorship Program instituted a full time Data Analyst (DA) to assist in identifying survivors using the OncoLog Cancer Registry and the Electronic Medical Record (EMR). Previously the identification process was limited to the EMR, and the Survivorship Program Nurse Coordinator (NC) was a combined role overseeing metrics, identifying patients and assisting with SVs. Currently the DA has piloted a method extracting data monthly from OncoLog and the EMR to assess eligibility of Standard 3.3. The data is compiled and sent to the NC who assists the cancer-specific service lines responsible for the patients identified to ensure SVs occur in a timely manner. Results: Our pilot intervention resulted in a 283% increase in SVs per month, from an average of 30 SVs to 115 SVs per month. The overall achievement for the CoC SV delivery requirement increased from 16% prior to the intervention to 33% in just 3 months. GI increased from 5% to 20%. Lung increased from 16% to 39%. The average SV was 3 months after the end of treatment. Approximately 60 hours was dedicated to establishing this method and 35 hours per month in the eligibility, identification process. Conclusions: By adding a DA role, extracting data from Oncolog and the EMR, as well as increasing accountability at the service line level to improve identification and scheduling of eligible patients, the delivery of SCPs to eligible patients substantially increased. Nevertheless this process is time consuming and will likely not be sufficient to ensure that all eligible survivors receive appropriate care. Consequently, additional, systematic improvements in this process should be explored such as EMR methodologies to automate patient identification.
Background: Failed implementation of health programs is common and may contribute to health disparities in resource-poor communities. We aimed to (1) evaluate barriers and facilitators for implementation of cancer survivorship services in rural communities and to (2) identify optimal strategies for successful implementation of survivorship care programs in these settings. Methods: The study design was guided by the Consolidated Framework for Implementation Research (CFIR) and based on the core principles of effective teamwork. We collected qualitative and quantitative data to assess barriers and facilitators to implementation of rural cancer survivorship care (3 focus groups, size 8, 31, and 77). Data were collected using both in-person and web-based approaches (semi-structured interviews, stakeholder surveys, ThinkTank, project online portal, Google Analytics). Stakeholders included cancer survivors, their families and caregivers, local public services administrators, health providers, and allied health-care professionals from rural and remote communities in Upstate New York. Results: Patients reported preferences for cross-region team-based survivorship care and emphasized the importance of including local providers on regional care teams and networks. Synthesis of results was guided by teamwork principles. Most rural patient stakeholders trusted recommendations received from their local providers (n=6, 86%) and preferred receiving care locally (n=6, 86%). Involvement of rural patient navigators (average rank 1.5 out of 5) and county care managers (1.9) was ranked more favorably than reliance on telemedicine alone (3.3) or visiting practice facilitators (3.3). Rural counties that have existing formal and informal networks involved in cancer care scored higher on the metrics of teamwork and demonstrated more advanced readiness to change in regards to survivorship program implementation. Conclusions: Our analysis identified a unique combination of community socio-economic factors, geographic isolation, and limited provider supply common in rural care settings as barriers to optimal delivery of cancer survivorship care in rural settings. We propose teamwork training and facilitation as an innovative implementation strategy to overcome these barriers and minimize their effect on patient access to care. Merging implementation science and team science frameworks could further assist with program adaptation to minimize implementation failure and improve continuity of care for complex cancer pathway management.
37 Background: Quality cancer survivorship care has multiple missions 1) develop personalized disease-specific treatment summaries (TS) and evidence-based survivorship plans (SPs), 2) foster recognition amongst Primary Care Providers (PCPs) of the consequences of cancer and its therapy, 3) coordinate care amongst providers, 4) use technology to foster communication and mining data, 5) train residents/fellows, 6) determine knowledge gaps for research, 7) engage community health providers, 8) publicize and raise funds, and 9) develop metrics to assess outcomes. Here we describe initial steps toward these goals. Methods: The University of Rochester Judy DiMarzo Cancer Survivorship program is a multidisciplinary effort across 7 centers involving oncologists, PCPs, social workers, integrated oncology, legal/financial services, and survivors. Survivors are identified at two critical time points: after (1) completion of primary curative therapy = transition visit, (2) discontinuation of routine oncologic follow-up and transition of care to their PCP = shared care visit. These visits are staffed within each cancer discipline. Trainees (15-20/year) probe existing evidence and draft TS/SP templates that are vetted by that cancer discipline. Patient needs are surveyed; institutional and community resources are identified. Results: In 3 years, 1037 patients had survivorship visits - 859 transition visits, 178 shared care visits. Cancers include breast (31%), head & neck (17%), lymphoma (15%), GI (15%), GU (11%), GYN (7%), lung (3%), melanoma and sarcoma (1%) with continuing refinement of systematic patient identification. Visits by year were: 120 in 2013, 266 in 2014, and 470 in 2015. Amongst the 1037 patients, the 6 most common needs were exercise, emotional, return to work, nutrition, financial, and pain. Conclusions: Our program is systematically embracing challenges to deliver evidence-based, individualized TS/SPs for survivors, as well as train future oncology providers in survivorship care. Current areas of focus are better engaging PCPs, ensuring program sustainability, improving technology use to mine data, measuring outcomes, establishing rural outreach, and fostering survivorship research.
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