The PREPARE for Your Care program increases advance care planning engagement among diverse older adults with cancer.

BACKGROUND: Advance care planning (ACP) is low among older adults with cancer. In a secondary analysis of randomized trial data, the authors compared the efficacy of the PREPARE for Your Care (PREPARE) website plus an easy-to-read advance directive (AD) with an AD only among older adults with and without cancer. METHODS: Safety net, primary care patients in San Francisco were included if they were 55 years old or older, were English- or Spanish-speaking, and had 2 or more chronic conditions. The authors determined cancer diagnoses by using International Classification of Diseases, Ninth Revision/Tenth Revision codes. The primary outcome was new ACP documentation in the medical record at 15 months; the secondary outcomes were self-reported ACP engagement, ease of use, satisfaction, and depression/anxiety. The authors used mixed effects logistic and linear regression adjusted for prior ACP, health literacy, and clinician, including a cancer interaction term. RESULTS: Of 986 participants, 220 (22%) had cancer. The mean age was 63 years (SD, 6 years), 61% were women, 81% were of a minority race/ethnicity, 45% were Spanish-speaking, 39% had limited health literacy, and 27% had prior ACP. New ACP documentation was higher in the PREPARE arm versus the AD-only arm among participants with cancer (62% vs 43%; P = .01) and without cancer (38% vs 28%; P = .01), as was ACP engagement in both arms (P < .001), with no interactions by cancer. Ease of use and satisfaction were high, and depression/anxiety was low, with no differences by study arm or by cancer/no cancer. CONCLUSIONS: PREPARE plus an easy-to-read AD increased ACP documentation and engagement among diverse older adults with cancer more than an AD alone, with no increase in depression or anxiety between study arms or by cancer. PREPARE may help to decrease ACP disparities among patients with cancer. LAY SUMMARY: Advance care planning (ACP) is the process of sharing values, goals, and preferences for medical care, but engagement in ACP is low among older adults with cancer. Among 986 English- and Spanish-speaking older adults from a safety net hospital, an interactive, multimedia, web-based ACP program (PREPARE for Your Care at https://prepareforyourcare.org/) plus an easy-to-read advance directive increased ACP documentation and engagement more than an advance directive alone. There were no differences in this increase in ACP between older adults with cancer and older adults without cancer. Also, engaging in ACP did not result in increased depression or anxiety.

Staffing in California Public Hospital Palliative Care Clinics: A Report from the California Health Care Foundation Palliative Care in Public Hospitals Learning Community.

Background: Although clinic-based palliative care (PC) services have spread in the United States, little is known about how they function, and no studies have examined clinics that predominantly serve safety net populations. Objectives: To describe the PC clinics operating in safety net institutions in California. Design: Survey completed by PC program leaders Setting/Subjects: PC programs in California, USA, safety net medical centers. Measurements: Descriptive statistics regarding staffing, clinic processes, patients served, and finances. Results: Twelve of 15 programs responded; 10 clinics that met inclusion criteria. All 10 programs use multiple disciplines to deliver care. Average full-time equivalent (FTE) used to staff an average of 2.75 half-day clinics per week includes 0.69 physician FTE, 0.51 nurse practitioner FTE, 1.37 nurse FTE, 0.79 social worker FTE, and 0.52 chaplain FTE. Clinic session schedules include an average of 1.88 new patient appointment slots (standard deviation [SD] = 0.44) and four follow-up appointment slots (SD = 1.95). The nine programs that reported on clinic volumes see 1081 patients annually combined, with an annual average of 120 (SD = 48.53) per program. Encounters per patient averaged 3.04 (SD = 1.59; eight programs reporting). All reported offering seven core PC services: pain/symptom management, comprehensive assessment, care coordination, advance care planning, PC plan of care, emotional support, and social service referrals. An average of 77.4% (SD = 26.81) of clinic financing came from the health systems. Conclusions: Our respondents report using an interdisciplinary team approach to deliver guideline-concordant specialty PC. More research is needed to understand the most effective and efficient staffing models for meeting the PC needs of the safety net population.

Generalist Palliative Care in the California Safety Net: A Structured Assessment to Design Interventions for a Range of Care Settings.

BACKGROUND: To provide high quality care to all patients who have serious illness, health-care systems must develop effective generalist palliative care strategies. OBJECTIVE: To identify palliative care quality gaps within a range of settings in the California safety net and to develop theory-based interventions to address them. DESIGN: Structured assessment using the National Consensus Project for Quality Palliative Care Clinical Practice Guidelines and a Predisposing, Reinforcing, and Enabling Constructs in Educational/Environmental Diagnosis and Evaluation intervention planning model-based worksheet, which integrates behavior theories to identify factors that predispose, enable, and reinforce clinicians to perform recommended behaviors. SETTING AND PARTICIPANTS: Adviser pairs-one from palliative care and one from a partner service line-from 10 California public health-care systems conducted assessments at their sites. A steering committee provided educational webinars, best practices, and assessment tools. MEASUREMENTS: Adviser pairs interviewed at least 6 partner service line stakeholders to identify palliative care quality gaps, behaviors clinicians should perform to close gaps, and factors that predispose, enable, and reinforce those behaviors. RESULTS: Partner service lines were primary care (n = 4), surgery (n = 3), emergency department (n = 2), and radiation oncology (n = 1). Selected gaps were advance care planning and goals of care communication (n = 6), identifying patients with serious illness (n = 3), and pain management (n = 1). All sites designed multiple interventions to address gaps, based on factors that predispose, enable, and reinforce a target audience to perform a target behavior. Advisers reported that the program strengthened relationships between palliative care and the partner service line. CONCLUSION: This structured assessment helped busy clinicians develop theory-based generalist palliative care interventions.

Psychosocial distress among oncology patients in the safety net.

OBJECTIVE: Psychosocial distress among cancer patients leads to poor health outcomes and lower satisfaction. However, little is known about psychosocial distress among disadvantaged populations. We examined the prevalence, predictors, and follow-up experience of psychosocial distress among cancer patients within a diverse, urban, and multi-lingual safety-net setting. METHODS: We conducted a retrospective cohort study of cancer patients undergoing psychosocial distress screening at initial medical oncology visits from 2014-2016. The primary outcome was self-reported moderate to severe psychosocial distress, defined by the NCCN as a Distress Thermometer score ≥ 4. Predictors of distress were assessed using logistic regression. Patients reporting distress were contacted by telephone 1-12 months later to reassess distress and assess completion of supportive service referrals. RESULTS: Among 200 screened patients, 61% had moderate to severe psychosocial distress. African-American race, psychiatric illness, greater number of emotional problems, and reported problems with housing, money, worry, sleep, memory or homelessness were associated with psychosocial distress. Among 39 patients with moderate to severe psychosocial distress who completed follow-up (42% of eligible patients), mean distress scores decreased from 6.5 at screening to 4.5 at follow-up (P < .02). 56% of the supportive service referrals made at the initial visit were not completed. CONCLUSIONS: Cancer patients in the safety-net experience more psychosocial distress than other populations, with persistently elevated distress levels and difficulty accessing supportive services. We identified subgroups that may be at higher risk for psychosocial distress. Closer follow-up and assistance for patients who report high distress levels may be needed.

Palliative Oncologic Care Curricula for Providers in Resource-Limited and Underserved Communities: a Systematic Review.

Familiarity with principles of palliative care, supportive care, and palliative oncological treatment is essential for providers caring for cancer patients, though this may be challenging in global communities where resources are limited. Herein, we describe the scope of literature on palliative oncological care curricula for providers in resource-limited settings. A systematic literature review was conducted using PubMed, Embase, Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Med Ed Portal databases, and gray literature. All available prospective cohort studies, case reports, and narratives published up to July 2017 were eligible for review. Fourteen articles were identified and referenced palliative care education programs in Argentina, Uganda, Kenya, Australia, Germany, the USA, or multiple countries. The most common teaching strategy was lecture-based, followed by mentorship and experiential learning involving role play and simulation. Education topics included core principles of palliative care, pain and symptom management, and communication skills. Two programs included additional topics specific to the underserved or American Indian/Alaskan Native community. Only one program discussed supportive cancer care, and no program reported educational content on resource-stratified decision-making for palliative oncological treatment. Five programs reported positive participant satisfaction, and three programs described objective metrics of increased educational or research activity. There is scant literature on effective curricula for providers treating cancer patients in resource-limited settings. Emphasizing supportive cancer care and palliative oncologic treatments may help address gaps in education; increased outcome reporting may help define the impact of palliative care curriculum within resource-limited communities.

Identifying Opportunities to Improve Pain Among Patients With Serious Illness.

CONTEXT: Pain is a common and distressing symptom. Pain management is a core competency for palliative care (PC) teams. OBJECTIVE: Identify characteristics associated with pain and pain improvement among inpatients referred to PC. METHODS: Thirty-eight inpatient PC teams in the Palliative Care Quality Network entered data about patients seen between December 12, 2012 and March 15, 2016. We examined patient and care characteristics associated with pain and pain improvement. RESULTS: Of patients who could self-report symptoms, 30.7% (4959 of 16,158) reported moderate-to-severe pain at first assessment. Over 40% of these patients had not been referred to PC for pain. Younger patients (P < 0.0001), women (P < 0.0001), patients with cancer (P < 0.0001), and patients in medical/surgical units (P < 0.0001) were more likely to report pain. Patients with pain had higher rates of anxiety (P < 0.0001), nausea (P < 0.0001), and dyspnea (P < 0.0001). Sixty-eight percent of patients with moderate-to-severe pain improved by the PC team's second assessment within 72 hours; 74.7% improved by final assessment. There was a significant variation in the rate of pain improvement between PC teams (P < 0.0001). Improvement in pain was associated with improvement in anxiety (OR = 2.9, P < 0.0001) and dyspnea (OR = 1.4, P = 0.03). Patients who reported an improvement in pain had shorter hospital length-of-stay by two days (P = 0.003). CONCLUSION: Pain is common among inpatients referred to PC. Three-quarters of patients with pain improve and improvement in pain is associated with other symptom improvement. Standardized, multisite data collection can identify PC patients likely to have marked and refractory pain, create benchmarks for the field, and identify best practices to inform quality improvement.

Starting and Sustaining Palliative Care in Public Hospitals: Lessons Learned from a Statewide Initiative.

BACKGROUND: Compared with private, not-for-profit hospitals, significantly fewer public hospitals report that they provide palliative care services for their patients. Because uninsured and underinsured patients largely depend on public hospitals for acute medical care, they therefore experience disparities in access to inpatient palliative care services. To address this disparity, the statewide Spreading Palliative Care in Public Hospitals Initiative (SPCPHI) was established to help implement or expand inpatient palliative care services in all 17 of California's public acute care hospitals. AIM: The aim of this article is to use the experiences from the SPCPHI to describe the unique challenges to providing palliative care in public hospitals; the major barriers to initiating, growing, and sustaining palliative care programs in public hospitals; and the common solutions to overcoming those barriers. CONCLUSIONS: Palliative care programs in public hospitals must develop the necessary skills and staffing to meet the complex needs of vulnerable patients and their families. These programs face a variety of unique organizational and operational challenges such as limited and uncertain funding, limited access to hospital data and analytic support, and complex regulatory structures, which may hinder growth of palliative care in these systems. Experiences from the SPCPHI suggest that networking, technical assistance, and startup funding are helpful to overcome these barriers and to develop high-quality, sustainable palliative care programs in public hospitals.

The Cambia Sojourns Scholars Leadership Program: Project Summaries from the Inaugural Scholar Cohort.

BACKGROUND: As palliative care grows and evolves, robust programs to train and develop the next generation of leaders are needed. Continued integration of palliative care into the fabric of usual health care requires leaders who are prepared to develop novel programs, think creatively about integration into the current health care environment, and focus on sustainability of efforts. Such leadership development initiatives must prepare leaders in clinical, research, and education realms to ensure that palliative care matures and evolves in diverse ways. METHODS: The Cambia Health Foundation designed the Sojourns Scholar Leadership Program to facilitate leadership development among budding palliative care leaders. RESULTS: The background, aims, and results to date of each of the projects from the scholars of the inaugural cohort are presented.