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

项目总结。癌症幸存者有独特的医疗需求，包括严重后遗症的风险， 正在进行的监测，改变生活方式以降低第二次癌症风险，以及心理社会支持。差一点 70%的患者被认为是“复杂的癌症幸存者”，因为他们至少患有一种慢性疾病 除了癌症。合并症对提供高质量的癌症护理构成了巨大的挑战，因为它们 对癌症治疗产生不利影响并受其影响。医疗服务不足的患者负担最重 癌症患者患有多种慢性病，在癌症治疗期间和治疗后出现不良结果的风险增加。AS 医疗服务不足的复杂癌症患者可能缺乏医疗保健知识和获得支持性护理的机会， 通过加强沟通和合作，他们的健康结果和护理过渡可能会得到改善 在他们的肿瘤学家和初级保健提供者(PCP)之间。这项研究测试和评估了一部共享的小说 复杂癌症幸存者的护理模式称为优化(肿瘤学-初级保健伙伴关系)以改善 全面生存护理)在德克萨斯州休斯敦最大的安全网医疗系统中。三百元 新诊断的乳腺癌、胃肠道和血液癌患者正在接受有治疗意向和 在癌症治疗期间有需要持续治疗的合并症患者将完成基线调查 随机分为优化组或普通医疗组(UMC)。接受UMC治疗的患者将收到他们的 癌症治疗，由他们的肿瘤学家指导，在积极治疗结束时制定生存护理计划(SCP)， 并根据国家指导方针与他们的肿瘤医生进行监视访问。处于优化状态的患者将有1)个 肿瘤科护士导航员在诊断时被分配到他们的护理团队，以促进肿瘤科医生与PCP的沟通 和连续性护理；2)在整个癌症过程中接受肿瘤医生和PCP之间的协调护理 通过有组织的沟通和转诊过程促进治疗和监测；3)获得 治疗结束时的生存护理计划(SCP)，包括共病管理；以及，4)接受 治疗后监测的风险分层共享护理模式，其中一名或多名常规肿瘤医生跟踪- UP访问被PCP访问所取代。目的1评价优化器对慢性病患者自身的影响 管理(主要结果)和生活质量(次要结果)。目标2探索优化的效果 关于积极的癌症治疗期间和之后的医疗保健使用和患者未得到满足的需求。目标3检查了这些影响 优化肿瘤学家和初级保健医生的态度以及护理的协调。目标4试图阐明患者-和 可能影响执行结果的系统层面的因素。优化改变了思考以下问题的时机 存活到诊断点，并寻求开发临床基础设施，以支持从 通过治疗后存活期进行癌症诊断。如果发现有效，优化可以扩展到其他 癌症，点燃了一个潜在丰富的研究领域。它还可能对其他地区产生重大的下游影响 通过加强从专科到初级保健的护理过渡，改善医疗环境。

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.