Strategies for Improving Access to Cancer Services in Rural Communities: A Pre-implementation Study

Abstract

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.

Availability of cancer care services and the organization of care delivery at critical access hospitals

“…Our survey identified that CAHs are regularly 39 collaborating with community organizations to support CAH capacity to meet patients' needs before and during a cancer diagnosis, especially by providing resources for cancer screening, education, and awareness, as well as support services for individuals with cancer and their families. To further enhance this capacity, we can look to previous work on models of cancer care coordination in rural settings, which promote models of cross‐region provider collaboration and care coordination 40 . In 2019, the American Society of Clinical Oncology hosted a forum titled Closing the Rural Cancer Care Gap, which looked for opportunities and best practices, noting a number of opportunities related to care coordination including working with community leaders to assess local gaps in cancer care and provide community‐based solutions 21 …”

“…To further enhance this capacity, we can look to previous work on models of cancer care coordination in rural settings, which promote models of cross-region provider collaboration and care coordination. 40 In 2019, the American Society of Clinical Oncology hosted a forum titled Closing the Rural Cancer Care Gap, which looked for opportunities and best practices, noting a number of opportunities related to care coordination including working with community leaders to assess local gaps in cancer care and provide community-based solutions. 21 Going forward, there are a variety of innovative ways in which CAHs may further confront the cancer care needs of their rural communities, including by building relationships with non-local providers and using telemedicine to improve barriers in access.…”

Unmet Needs and Care Delivery Gaps Among Rural Cancer Survivors

“… 14 While services are commonly available in comprehensive cancer care settings, once patients conclude treatment and resume routine healthcare follow up in their community, specialized support services are lacking. 15 This is especially true in rural areas of the US, where access to supportive care providers with expertise in oncology is limited. 16 , 17 …”

The Colocation Model in Community Cancer Care: A Description of Patient Clinical and Demographic Attributes and Referral Pathways

“…[23][24][25][26] There is a large evidence base documenting communitybased and culturally relevant approaches to cancer care in historically marginalized populations. [27][28][29][30][31][32] Although programs exist that focus on expanding access based upon particular cancers [33][34][35][36] or on disease-specific integration of care, 37 broad-based access programs have been more challenging to establish and sustain. 38 To date, there are few community-based clinical interventions that expand access to a National Cancer Institute (NCI)-Designated Cancer Center across disease types.…”