FACTORS IMPACTING MULTIDISCIPLINARY TEAM COMMUNICATION AND PATIENT-CENTERED COMMUNICATION ALONG THE CANCER CARE CONTINUUM

The deployment of navigators as liaisons between cancer patients and their Multi-Disciplinary Teams (MDT) affords a high level of coordinated care that is otherwise difficult to attain. Highly functioning navigators provide a multitude of support roles, the primary being the dissemination and interpretation of information to and from patients and providers in a manner that is digestible to all recipients. Navigators face hurdles in the form of communication breakdowns within the MDT which can negatively impact level of care and lead to patient uncertainty. Patients face additional barriers of their own which serve to further heighten uncertainty and cause patients to seek additional resources to support their decision-making process as they traverse the cancer care continuum. Interviews were conducted with ten (n = 10) multidisciplinary cancer care team members, as well as ten (n = 10) navigators to determine factors affecting the navigator\u27s liaison function between the patient and multidisciplinary team (MDT). In depth interviews were also conducted with ten (n = 10) cancer patients to better understand how they manage uncertainty when making medical decisions in the absence of sufficient communication with the MDT and/or navigator. MDT members and navigators’ interviews revealed communication breakdowns within the MDT that fell into six thematic categories: opacity of the navigator role, MDT collaborative care deficiencies, incompatible modes of team communication, scarcity of time, perceived financial limitations of the navigator position, and suboptimal dissemination of patient health information. Each theme is underpinned by data offering insight into refinements that can be implemented to enhance the navigator’s boundary spanning function. Patient interviews offered insight into how they managed uncertainty and made medical decisions in the absence of sufficient communication with their MDT. The researcher aimed to determine avenues of resolution, but it became evident that the cause of the communication breakdown and the patients’ subsequent decision-making processes were intrinsically linked. Analysis revealed several thematic categories of compromised patient-provider communication and how the patients subsequently dealt with these limitations including: patient shock at the time of diagnosis, insufficient pre-treatment (health information) and post-treatment (inconsistent) communication, and patient exclusion from care planning. Findings from this research are multi-faceted and far reaching in scope with applications to coordination and quality of care, impact to health, patient satisfaction, and perhaps even hospital profitability. Analysis of the research data obtained from patient and MDT member interviews allowed for identification of barriers affecting communication between the MDT, navigator, and patient, and illuminated appropriate adjustments that could be implemented to improve communication and quality of care

Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Striving for Equity in Specialty Care Full Report

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.

Addressing Barriers to Breast Cancer Care in California: The 2016 - 2017 Landscape for Policy Change

In 2018, over 29,000 women will be diagnosed with breast cancer in California and an estimated 4,500 will die of the disease. While the Affordable Care Act (ACA) has successfully expanded access to health insurance and breast cancer care, numerous population subgroups remain uninsured, and many others may lack adequate coverage for treatment and management of their breast cancer. Although insurance improves breast cancer outcomes compared to those with no insurance, challenges may remain even for the insured. Among those insured, there appear to be significant barriers to cancer care as health insurance premiums are increasing, networks are narrowing, and as the cost of breast cancer drugs is increasing.This report provides a comprehensive assessment of the significant barriers and challenges to accessing breast cancer care in California through the  completion of three key tasks: (1) a synthesis of the peer reviewed literature, news media, reports and policy briefs, (2) completion of a series of key informant/stakeholder interviews, and (3) an analysis of social media. The authors find five categories of barriers: (1) Health System Barriers, (2) Insurance Barriers, (3) High Costs, (4) Individual and Cultural Characteristics, and (5) Language.Although many barriers are shared across insurance types, where possible, this report provides insight on barriers unique to the insurance status of women, specifically for the uninsured, those covered by Medi-Cal, and those covered by commercial insurance. Findings from this report can be used to guide efforts of policymakers to improve timely access to breast cancer care among all women in California

Longitudinal evaluation of ‘Navigation’, a decision support intervention for patients with colorectal cancer and high grade glioma:a mixed methods study

Introduction: At the core of UK policy for improving outcomes in cancer are goals for a healthcare where patients are empowered through information enabling engagement in shared care decisions with clinicians. Interventions to support patients’ engagement in shared decision making are lacking within colorectal cancer and high grade glioma care despite intensive treatment regimens with uncertain outcomes. Navigation, a communication and decision support intervention, has been successfully piloted with prostate and breast cancer patients who demonstrated significantly more confidence and less uncertainty in their treatment decisions. With healthcare policy advocating patients be educated and engaged in their care, the applicability of this intervention to other cancer settings is required. The Navigation intervention includes: consultation planning with a Navigator, formulation of a consultation plan and recording (summary and CD) of the medical consultation. Objectives: To determine the effectiveness of the Navigation intervention in enhancing decision-making quality over time when compared with usual care, in patients with colorectal cancer. To explore repeated experiences of the Navigation intervention from the perspective of colorectal cancer (CRC) patients, patients with high grade glioma (HGG), and consulting clinicians. Design and Studies: A mixed methods study using a pragmatic randomised controlled trial and qualitative evaluation was undertaken during November 2010 – December 2013. The intervention was trialled separately with two cohorts of cancer patients (CRC and HGG). A longitudinal parallel-group pragmatic randomised controlled trial was conducted. Study 1 consisted of a longitudinal parallel-group pragmatic randomised control trial. Participants with colorectal cancer were openly randomised after completion of baseline measures to receive the intervention or usual care (no intervention). The intervention was administered to patients at three particular time points during first line cancer treatment. Participants completed tools collecting primary outcome (decision self-efficacy) and secondary outcomes (decision conflict, decision regret, anxiety and depression) measured prior to baseline, post consultation and at follow-up. Mean change in scores overtime and between groups were compared using Mixed ANOVAS. Study two was a prospective qualitative study undertaking serial in-depth semi-structured evaluation interviews with patients with High Grade Glioma. Study three undertook interviews with the consulting HGG and CRC clinicians. Framework analysis was undertaken. Setting: Two oncology settings within a tertiary cancer centre in Scotland. Participants: 132 patients with colorectal cancer (65 intervention, 67 control) participated in the randomised controlled trial. For the qualitative study, 17 colorectal trial participants (8 intervention, 9 control), 11 high grade glioma patients and 7 clinicians were interviewed. Evaluation Results: No significant difference was found between the control and Navigation intervention participants over time in the primary outcome of decision self-efficacy, or in the following secondary outcomes; decision conflict or anxiety and depression scores. At follow-up, the intervention group reported significantly less decision regret than the controls (p=0.039). In the qualitative data, Navigated participants reported being well prepared for medical consultations, able to actively engage in information exchange during consultation and enabled to recall and understand information provided. This was in contrast to participants receiving usual care who described being less prepared for medical consultations and experienced barriers to gathering information, such as time pressures, forgetting questions, and gaps in understanding. Clinicians identified that patients benefitted from preparing for, and having a written summary of, the consultation. Whereas neuro-oncology clinicians were supportive of Navigation as a tool to tailor information to patients; colorectal clinicians felt Navigation was a disruption to their normal consultation routine. Concern was expressed regarding the extra resource required by Navigated patients and therefore about the feasibility and sustainability of the intervention. Conclusions: Whilst models of shared decision making remain highly profiled in cancer strategies, information exchange and use of interventions in context is problematic. This evaluation of Navigation has demonstrated more impact on the process of decision making, rather than outcome per se, and has raised questions about its sustainability in clinical practice. A more nuanced understanding of different cancer pathways and the specific decisions to be made, may inform a more targeted use of decision support in cancer car

Is This Going to Be the End? Understanding Problematic Integration Among Appalachian Patients in Colorectal Cancer Screening Navigation

Colorectal cancer (CRC) is preventable through regular screening; however, incidence and mortality rates in Appalachia are among the highest in the United States. Public health programs and interventions meant to mitigate the higher CRC burden and increase screening rates are ongoing in the U.S. and Appalachia. In continuing the efforts to reduce the burden of CRC in Appalachian communities, this dissertation uses a two-part study to investigate communication practices relative to problematic integration and health beliefs in CRC screening conversations from the perspective of both patients and patient navigators in the region. As part of efforts directed by the Rural Cancer Prevention Center (RCPC; 2009-2019), patients who received a positive fecal immunochemical test (FIT) and the patient navigators assigned to connect them with direct visualization follow-up testing were interviewed one-on-one to better understand the role of problematic integration in CRC screening communication. Study 1 investigates patient navigators\u27 (n = 9) perspectives of their efforts to connect patients with appropriate CRC screening, while Study 2 analyzes the accounts of patients (n = 10) with positive FIT who refused follow- up colonoscopy testing (at the time of recruitment) after engaging in patient navigation services. With problematic integration theory and the health belief model as a guide, data from these two studies in the Appalachian Kentucky context support an overarching model for how patient navigators and patients address uncertainty in CRC screening. Analyzing these phenomena at the intersection of communication and health behavior theories highlights the utility of health communication research expertise in guiding interventions across the healthcare continuum. In addition, data from the studies may be used to understand the nature of participation in CRC screening conversations and how these dynamics contribute to patient-centered care and shared decision-making, which is especially important with the additional challenges for screening exacerbated by a global COVID-19 pandemic. The findings from these studies are discussed in terms of contributing to more effective clinical and patient navigation communication practices and providing public health practitioners with essential considerations for shaping interventions to support shared decision-making and improve CRC screening rates in similar populations

Changing Needs of Individuals with Disabilities in the Time of COVID-19 as Observed by a Family Navigation Program in Miami, FL

The Family Navigator Program (FNP) is designed to help families navigate the complex system of services available to people with intellectual and developmental disabilities (I/DD), chronic health conditions, mental health issues, and other special health care needs. Based at the Mailman Center for Child Development at the University of Miami, the FNP is free and available to all families in South Florida. Most families enrolled in the FNP are receiving medical services from a university clinic; however, the program also accepts referrals from outside agencies and self-referrals. The aim of this study was to investigate the needs of families enrolled in the FNP before and after March 2020, when stay-at-home orders were put in place to address the COVID-19 pandemic. One hundred forty-five families enrolled in the FNP between November 2019 and mid-March 2020 were selected as a pre-COVID sample to be compared with 197 families enrolled from mid-March to September 2020. Families were deidentified, and data on demographics and specific needs were extracted. Demographics included race and ethnicity, language, age group, zip code, and disability or medical condition. Specific needs were defined as (1) topics on which families required education and (2) resources to which families were referred. There were no statistically significant differences in demographics before and after March 2020. There was a significant increase in referrals to financial resources during COVID (OR= 3.019, 95% CI [1.445-6.308]). There were also significant changes in the number of families provided with education on the following: increases in federal and state programs (OR = 2.156, 95% CI [1.306-3.560]) and other miscellaneous topics (1.902, 95% CI [1.081-3.348]); and decreases in school systems (OR=0.531 CI, 95% [0.328-0.858]) and therapies (CI, 95% [0.345-0.825]). These differences likely reflect the economic and social toll that the pandemic has taken on families caring for individuals with IDD and special health care needs in South Florida. Families’ priorities shifted from school and therapy to economic needs. The FNP adjusted by administering services by telephone or online, rather than by in-person meetings. These data provide a snapshot of how the needs of families changed during COVID-19 in one diverse, urban community

Women’s responses to changes in U.S. preventive task force’s mammography screening guidelines: results of focus groups with ethnically diverse women

Background: The 2009 U.S. Preventive Services Task Force (USPSTF) changed mammography guidelines to recommend routine biennial screening starting at age 50. This study describes women’s awareness of, attitudes toward, and intention to comply with these new guidelines. Methods: Women ages 40–50 years old were recruited from the Boston area to participate in focus groups (k = 8; n = 77). Groups were segmented by race/ethnicity (Caucasian = 39%; African American = 35%; Latina = 26%), audio-taped, and transcribed. Thematic content analysis was used. Results: Participants were largely unaware of the revised guidelines and suspicious that it was a cost-savings measure by insurers and/or providers. Most did not intend to comply with the change, viewing screening as obligatory. Few felt prepared to participate in shared decision-making or advocate for their preferences with respect to screening. Conclusions: Communication about the rationale for mammography guideline changes has left many women unconvinced about potential disadvantages or limitations of screening. Since further guideline changes are likely to occur with advances in technology and science, it is important to help women become informed consumers of health information and active participants in shared decision-making with providers. Additional research is needed to determine the impact of the USPSTF change on women’s screening behaviors and on breast cancer outcomes

A spectrum of approaches to health information interaction: From avoidance to verification

People respond to illness in a range of ways, and take different approaches to engaging with health information throughout the course of their illness. This study describes and explains the variety of approaches to health information interactions made by patients on hemodialysis. Ethnographic observations (156 hours) were conducted in three hemodialysis clinics, and semistructured interviews about health information were held with 28 patients. Demographic data were collected. Data were analyzed qualitatively. We found a spectrum of five approaches to health information: avoiders, who close themselves off from health information; receivers, who encounter information in the dialysis clinic but do not seek it out; askers, who only pose questions about health to their healthcare providers but otherwise do not seek; seekers, who actively look for health information both in and out of the clinic; and verifiers, who seek information and triangulate it among multiple sources. Trust in healthcare providers and coping sociality differed across approaches. The findings indicate that health information should be provided to patients using strategies tailored to their preferences and existing approaches to information interaction.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156165/2/asi24310_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156165/1/asi24310.pd

The New York City Health and Hospitals Corporation: Transforming a Public Safety Net Delivery System to Achieve Higher Performance

Describes the results of the public benefit corporation's improvement initiatives -- a common clinical information system for continuity, coordination on chronic disease management, teamwork and continuous innovation, and access to appropriate care