OPTIMISE: A Shared Care Approach for Improving Comprehensive Care of Cancer Patients with Comorbidities in A Safety-Net System

OPTIMISE：一种共享护理方法，可在安全网系统中改善患有合并症的癌症患者的综合护理

• 批准号: 10408739
• 负责人: Hoda J Badr
• 金额: $ 64.45万
• 依托单位: BAYLOR COLLEGE OF MEDICINE
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-06-01 至 2026-05-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10408739
• 关键词: Accident and Emergency department; Address; Adherence; Adoption; Affect; Aftercare; Area; Attitude; Baseline Surveys; Cancer Patient; Cancer Survivor; Cancer Survivorship; Caring; Chronic; Chronic Disease; Clinic Visits; Clinics and Hospitals; Collaborations; Communication; Complex; Comprehensive Health Care; Continuity of Patient Care; Data; Diagnosis; Disease Management; Disease-Free Survival; Face; Feedback; Future; Goals; Guidelines; Health; Healthcare; Healthcare Systems; Hematologic Neoplasms; Individual; Interruption; Interview; Knowledge; Late Effects; Lead; Life Style Modification; Low income; Malignant Neoplasms; Malignant neoplasm of gastrointestinal tract; Medical; Methods; Modeling; Monitoring for Recurrence; Newly Diagnosed; Oncologist; Oncology; Oncology Nurse; Outcome; Outcome Assessment; Pathway interactions; Patient Care; Patients; Preventive care; Primary Health Care; Process; Protocols documentation; Provider; Psychosocial Assessment and Care; Public Hospitals; Qualitative Evaluations; Quality of life; Randomized; Randomized Controlled Trials; Reach Effectiveness Adoption Implementation and Maintenance; Recurrence; Reporting; Research; Resource-limited setting; Risk; Second Primary Cancers; Self Management; Structure; Supportive care; Surveillance Modeling; System; Testing; Thinking; Time; Translations; Uninsured; Visit; Visiting Nurse; active method; base; breast cancer diagnosis; cancer care; cancer diagnosis; cancer risk; cancer therapy; care coordination; care providers; care systems; chronic care model; clinical care; clinical infrastructure; clinical practice; collaborative care; comorbidity; ethnic minority; experience; follow-up; health care service utilization; implementation outcomes; improved; malignant breast neoplasm; medical specialties; medically underserved; multiple chronic conditions; novel; patient subsets; prevent; primary outcome; racial and ethnic; risk stratification; safety net; scale up; secondary outcome; survivorship; trend; uptake

PROJECT SUMMARY. Cancer survivors have unique healthcare needs including risk for serious late effects, ongoing surveillance, lifestyle modifications to reduce second cancer risk, and psychosocial support. Nearly 70% are considered “complex cancer survivors” because they have at least one comorbid chronic condition in addition to cancer. Comorbidities pose significant challenges to the delivery of quality cancer care because they adversely affect and are affected by cancer treatment. Medically underserved patients have the highest burden of multiple chronic conditions and are at increased risk for poor outcomes during and after cancer treatment. As medically underserved complex cancer patients may lack healthcare knowledge and access to supportive care, their health outcomes and care transitions might be improved by enhancing communication and collaboration between their oncologists and primary care providers (PCPs). This study tests and evaluates a novel shared care model for complex cancer survivors called OPTIMISE (Oncology-Primary Care Partnership to Improve Comprehensive Survivorship Care) in the largest safety-net healthcare system in Houston, TX. Three-hundred newly diagnosed breast, GI, and hematological cancer patients who are being treated with curative intent and who have comorbidities requiring ongoing management during cancer treatment will complete baseline surveys and be randomized to either OPTIMISE or Usual Medical Care (UMC). Patients receiving UMC will receive their cancer treatment, as directed by their oncologist, a survivorship care plan (SCP) at the end of active treatment, and surveillance visits with their oncologist based on national guidelines. Patients in OPTIMISE will 1) have an oncology nurse navigator assigned to their care team at diagnosis to facilitate oncologist-PCP communication and continuity of care; 2) receive coordinated care between their oncologist and PCP throughout cancer treatment and surveillance facilitated by a structured communication and referral process; 3) receive a survivorship care plan (SCP) at the end of treatment that incorporates comorbidity management; and, 4) receive a risk-stratified shared care model of post-treatment surveillance where one or more routine oncologist follow- up visits is replaced by a PCP visit. AIM 1 evaluates the impact of OPTIMISE on patient chronic disease self- management (primary outcome) and quality of life (secondary outcome). Aim 2 explores the effects of OPTIMISE on healthcare use and patient unmet needs during and after active cancer treatment. Aim 3 examines the effects of OPTIMISE on oncologist and PCP attitudes and coordination of care. Aim 4 seeks to elucidate patient- and system-level factors that may influence implementation outcomes. OPTIMISE shifts the timing of thinking about survivorship to point of diagnosis and seeks to develop a clinical infrastructure to support continuity of care from cancer diagnosis through post-treatment survivorship. If found effective, OPTIMISE could be expanded to other cancers, igniting a potentially rich area of research. It may also have significant downstream impact in other medical settings by enhancing care transitions from specialty to primary care.

项目总结。癌症幸存者有独特的医疗需求，包括严重的后期影响风险，